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Full text of "Hazardous materials release following the derailment of Baltimore and Ohio Railroad Company train no. SLFR, Miamisburg, Ohio, July 8, 1986"

PB87-9 17004 






For Reference 

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From the Library 



HE 

199.5 

.D3 

U581 

87/01 







NATIONAL %7i^oP^ 

TRANSPORTATION 

SAFETY 

BOARD 

WASHINGTON, D.C. 20594 

HAZARDOUS MATERIALS 
ACCIDENT REPORT 

HAZARDOUS MATERIALS RELEASE 
FOLLOWING THE DERAILMENT OF 
BALTIMORE AND OHIO RAILROAD COMPANY 
TRAIN NO. SLFR 
MIAMISBURG, OHIO 
JULYS, 1986 

NTSB/HZM-87/01 



UNITED STATES GOVERNMENT 






s -Uo -flt 7/yy3 



"n Report No. 

NTSB/HZM-87/01 



TECHNICAL REPORT DOCUMENTATIOH PA^^'^' 



2. Government Accession No. 
PB87-917004 



4. Title and Subt i tie fiHg(zai.(jous Materials Accident 
Report— Hazardous Materials Release Following the 
Derailment of Baltimore and Ohio Railroad Company Train 
No. SLFR. Miamisburg. Ohio. July 8. 1986 

7. Author(s) 



3 .Reci pient ' s Catalog No. 



5. Report Date 



6. Performing Organization 
Code 



8. Performing Organization 
Report No. 



9. Performing Organization Name and Address 

National Transportation Safety Board 
Bureau of Accident Investigation 
Washington, D.C. 20594 



lO.Work Unit No. 
4462A 



11. Contract or Grant No. 



12. Sponsoring Agency Name and Address 

NATIONAL TRANSPORTATION SAFETY BOARD 
Washington, D. C. 20594 



13. Type of Report and 
Period Covered 

Hazardous Materials 
Accident Report 
July 8, 1986 

l^* .Sponsor i ng Agency Code 



15. Suppi ementary Notes 



16. Abstract Qn July 8, 1986, 15 cars of a southbound Baltimore and Ohio Railroad Company 
freight train derailed while traveling at 45 mph near Miamisburg, Ohio. Three of the 15 
derailed cars were tank cars containing yellow phosphorus, molten sulfur, and tallow. While 
derailing on a bridge, these tank cars were extensively damaged, lost product, and were 
involved in the resulting fire. Approximately 7,000 residents from a section of Miamisburg 
were initially evacuated as a safety precaution. On the following day as a 
wreckage-clearing crew was preparing to remove the smoldering phosphorus tank car, a 
concrete structure supporting the tank car collapsed, and several hundred gallons of molten 
phosphorus inside the tank car escaped and ignited, resulting in an extensive cloud of 
phosphorus combustion effluents. During the following 48 hours, a 3-square-mile area of 
Montgomery County, Ohio, was evacuated, forcing an estimated 30,000 people to leave their 
homes and businesses; 569 persons were treated for various complaints during the incident. 
Total property damage was $3,540,000 including the cost of hazardous materials. 

The National Transportation Safety Board determines that the probable cause 
of the uncontrollable release of phosphorus was the failure of the unprotected bottom brake 
support attachment during the derailment resulting in the tearing of the tank shell. 
Contributing to the rupture of the tank was the Federal Railroad Administration's failure to 
require retroactively that reinforcement pads be installed between tank shells and welded 
attachments. 



/. ey or s tank car; fire; hazardous materials; 
emergency response; derailment; phosphorus; sulfur; 
tank car attachment; AAR; Tank Car Committee; FRA; 
delegation of authority 



19-Security Classification 
(of this report) 
UNCLASSIFIED 



20. Security Classification 
(of this page) 
UNCLASSIFIED 



l8.Di str i but ion Statement 

This document is available 
to the public through 
the National Technical 
Information Service, 
Springfield, Virginia 22161 



21 .No. of Pages 
94 



22. Price 



NTSB Form 1765.2 (Rev. 9/74) 



CONTENTS 

EXECUTIVE SUMMARY v 

INVESTIGATION 1 

The Accident 1 

Hazardous Materials Release 1 

Emergency Response 3 

Direct Hose Stream Attack 8 

Plugging 8 

Water Flooding of the Interior of the Phosphorus Tank Car 8 

Apply Foa m 8 

Burial 8 

Open Manhole 9 

Explosive Demolition 9 

Injuries to Persons 10 

Damage 10 

Meteorological Information 10 

Emergency Preparedness 11 

Product Information 11 

Yellow Phosphorus 11 

Sulfur 12 

Temk Car Information 13 

UTLX 79499 13 

UTLX 76486 15 

UTLX 77400 16 

Protection of Attachments 16 

Development of Tank Car Safety Standards 20 

Initial Tank Car Safety Program 20 

FRA Tank Car Safety Program 21 

AAR Tank Car Safety Program 24 

The Canadian Transport Commission 27 

Case History: FRA Oversight of AAR Tank Car Safety Activities 29 

ANALYSIS 36 

Emergency Response 36 

Initial Response Actions 36 

Longer-Term Actions 38 

Emergency Response Guides 39 

Tank Car Performance 40 

Tank Car Coupler and Thermal Insulation Performance 41 

Tank Car Attachment Performance 41 

Tank Car Safety Programs 43 

CONCLUSIONS 45 

Findings 45 

Probable Cause 47 

RECOMMENDATIONS 47 



CONTENTS (continued) 

APPENDIXES 51 

Appendix A— Investigation 51 

Appendix B— Railroad Accident/Incident Summary Report 52 

Appendix C— Safety Board Recommendations For Improvement of 

Hazardous Materials of Tank Car Safety 57 

Appendix D— Summary of Federal Railroad Administration Delegation of 

Authority to Association of American Railroads for Tank Car 

Safety and Related FRA and AAR Procedures and Operations 58 

Appendix E— Association of American Railroads Responses 

to Selected Questions 64 

Appendix F— Excerpts From Relevant Emergency Guides 

For Phosphorus 73 

Appendix G— Canadian Railways Transport Committee Board of Inquiry: 

MacMillan Yard Accident 77 



EXECUTIVE SUMMARY 

At 4:25 p.m., on July 8, 1986, 15 cars of a southbound Baltimore and Ohio Railroad 
Company freight train consisting of 44 ears and a locomotive, derailed while traveling at 
45 mph near Miamisburg, Ohio. Three of the 15 derailed cars were tank cars containing 
yellow phosphorus, molten sulfur, and tallow. While derailing on a bridge, these tank cars 
were extensively damaged, lost product, and were involved in the resulting fire. 
Approximately 7,000 residents from a section of Miamisburg were initially evacuated as a 
safety precaution. 

On the following day, as a wreckage-clearing crew contracted by the railroad was 
preparing to remove the smoldering phosphorus tank car, a concrete structure supporting 
the tank car collapsed, and several hundred gallons of molten phosphorus inside the tank 
car escaped and ignited, resulting in an extensive cloud of phosphorus combustion 
effluents. During the following 48 hours, a 3-square-mile area of Montgomery County, 
Ohio, was evacuated, forcing an estimated 30,000 people to leave their homes and 
businesses; 569 persons were treated for various complaints during the incident. Total 
property damage was approximately $3,540,000, including the cost of hazardous materials 
cleanup. 

Observation of emergency response activities and the conditions that led to 
hazardous materials release following the July 8, 1986, derailment in Miamisburg, Ohio, 
prompted the Safety Board to conduct this hazardous materials accident investigation. 
The investigation revealed that the major release of phosphorus came from a breach in 
the tank shell in an area where a bottom attachment was welded directly to the tank 
shell. Other tank shell failures at attachments have raised the Safety Board's concern 
about the adequacy of Federal safety standards and the Federal Railroad Administration's 
oversight of tank car performance. As a part of this investigation, the Safety Board 
reviewed the adequacy of the Federal Railroad Administration's delegation to the 
Association of American Railroads of tank car safety authority and how the FRA 
monitored actions taken by the AAR under the delegated authority. The safety issues 
discussed in this report are: 

o effectiveness of hazardous materials emergency response activities 
and guides inducing the outcome of the emergency; 

o crashworthiness of hazardous materials tank cars during 
derailments; and 

o effectiveness of FRA's delegation of authority to the AAR for tank 
car safety. 

As a result of its investigation, the Safety Board issued recommendations to improve 
the accuracy and consistency of information provided in emergency response guides; to 
identify and report tank car deficiencies; to determine the adequacy of tank car 
specifications; and to establish procedures for determining that tank car construction and 
repair comply with Federal standards. The Safety "^oard made recommendations to the 
Federal Railroad Administration, the Research and Special Programs Administration of 
the U.S. Department of Transportation, CSX Transportation, and the Association of 
American Railroads concerning these safety issues. 



The National Transportation Safety Board determines that the probable cause of the 
uncontrollable release of phosphorus was the failure of the unprotected bottom brake 
support attachment during the derailment resulting in the tearing of the tank shell. 
Contributing to the rupture of the tank was the Federal Railroad Administration's failure 
to require retroactively that reinforcement pads be installed between tank shells and 
welded attachments. 



NATIONAL TRANSPORTATION SAFETY BOARD 
WASHINGTON, D. C. 20594 

HAZARDOUS MATERIAI^ ACCIDENT REPORT 

Adopted: September 29, 1987 

HAZARDOUS MATERIALS RELEASE FOLLOWING 

THE DERAILMENT OF BALTIMORE AND OHIO RAILROAD COMPANY 

TRAIN NO. SLFR 

MIAMISBURG, OHIO 

JULY 8, 1986 

INVESTIGATION 

The Accident 

At 4:25 p.m., on July 8, 1986, 15 cars of southbound "altimore and Ohio Railroad 
Company 1/ (B&O) freight train Southland Flyer (SLFR), consisting of a locomotive and 44 
cars, derailed while traveling at 45 mph on a through-plate bridge 2/ (bridge 497 at 
milepost 49.7) spanning the Bear Creek at Miamisburg, Ohio. (See figure 1.) Train SLFR 
was being operated with all four crewmembers in the locomotive and with an 
"end-of-train" monitoring device. 3/ Three tank cars were breached and lost some or all 
of their contents. Within minutes, large plumes of smoke were emitted from the 
wreckage, and soon thereafter a large pool of spilled materials ignited. 

The locomotive and the 1st through the 27th cars remained coupled together and 
stopped 21,867 feet south of bridge 497. Four of these cars, the 24th through the 27th, 
were derailed but remained upright and separated from the trailing cars by 1,531 feet. 
The next 11 cars, the 28th through 38th, were derailed but remained aligned with the 
track structure and stopped south of the bridge. The remaining cars stopped on the north 
side of the bridge. (For more detailed information, see appendix B.) 

Hazardous Materials Release 

The 30th car, Union Tank Car Company (UTLX) 79499, a tank car loaded with yellow 
phosphorus, came to rest on its side south of the bridge with its dome rotated to the east 
approximately 45°. The tank car's 2 -inch water introduction pipe was open, the B-end 



1/ At the time of the accident, the Baltimore and Ohio Railroad Company was a 

subsidiary of the Chesapeake and Ohio Railway Company, and on May 1, 1987, the B&O 

merged into the C&O, a wholly owned subsidiary of CSX Corporation. 

2/ A bridge structure framed to allow the track to be supported at or near the bottom 

flanges of the plate girder. 

3/ A device that provides a red marker light at the end of a train not provided with a 

caboose. Additionally, by radio telemetry the end-of-train device provides the engineer a 

digital readout of the airbrake pressure at the end of the train and of any change in air 

pressure. 



-3- 



top washout nozzle along with the tank shell adjacent to the airbrake support bracket 
were breached during the derailment and subsequent fire, releasing thick clouds of 
phosphorus combustion effluents (see figure 2). Liquid phosphorus was released on to the 
ground through the 8 -inch tear in the bottom of the tank shell at the airbrake support 
bracket attachment. The exposed phosphorus smoldered and ignited within 15 minutes. 

The 33rd car, UTLX 76486, a tank car loaded with molten sulfur, began releasing its 
contents during the derailment just north of the bridge. This car came to rest straddling 
the south headwall of the bridge and just behind the 30th car. This car received three 
tank head punctures: the trailing head had a 24 -inch -long fracture and the leading head 
had both a 10-inch-diameter and a 28-inch-long fracture. A large volume of molten 
sulfur was released through these punctures and spilled onto the bridge and into the creek 
before the phosphorus ignited. 

The 34th tank car, UTLX 77400, containing tallow, came to rest on the south span of 
the bridge. The leading head had a puncture approximately 12 by 6 inches directly above 
the draft sill. Tallow was released into the creek through this puncture. 

Emergency Response 

Immediately after the derailment, the crew observed what appeared to be a dust 
cloud at the rear. The conductor reviewed the waybills to determine what "Dangerous" 4/ 
commodities might be involved. The waybills identified two tank cars (the 12th and 30th) 
as "Dangerous" and listed their commodities as sodium hydrosulfide and yellow 
phosphorus, respectively. The way bill for the phosphorus tank car (30th) also was marked 
"Poison." 5/ Shortly thereafter, the conductor and the front brakeman left the locomotive 
and began walking north along the forward portion of the train. While a crewmember 
could have approached from the rear safely, no one was sent to the rear of the train to 
determine which of those rail cars remained upright. Almost concurrently, about 
4:29 p.m., a nearby resident telephoned the Miamisburg police/fire dispatcher, and fire 
and police units were immediately dispatched. A city fire inspector, who was on the 
Sycamore Street Bridge near the accident site saw smoke coming from the derailed cars 
at 4:30 p.m. 

Shortly after 4:31 p.m., the first arriving local emergency personnel approached 
within 100 feet of the southwest side of the bridge. These first responders, a policeman 
and firefighter, reported that because of the thick smoke they could only see two tank 
cars (the 30th and 33rd) just south of the bridge. They saw the bottom of the 30th car 
facing west with a tear in its shell; they could not see the condition of the 33rd car. 
Placards were no longer in place on the ends and sides of the 30th car because they had 
been torn off during the derailment. Thus, the emergency responders were not alerted 
that the hazardous materials were involved in the derailment nor did they realize the need 
to wear personal protective equipment. They reported that "there was a small 
yellowish-white fire visible within the bottom of the one tank car [30th] and that a large 
cloud of very thick white smoke was billowing from the hole." 

When the conductor and front brakeman proceeded past the fourth car north of the 
locomotive, they saw billowing white smoke and cars on the ground south of the bridge. 
The conductor said that because he knew that two ears in the train contained hazardous 

4/ Title 49 CFR Section 174.25 requires "Dangerous" to be noted next to the car number 
on waybills, switching orders, and other billing for most classes of hazardous materials. 
5/ Denotes the Canadian subsidiary classification for phosphorus. 



-5- 



materials, he contacted the B&O Dayton dispatcher using his portable radio, reported the 
train's location, and requested local emergency assistance. At this time the conductor was 
unable to determine if either of the hazardous materials tank cars were involved in the 
derailment. At 4:37 p.m., the B&O Dayton dispatcher contacted the Miamisburg Police 
Department reporting "a train derailment on the Chessie System 6/ and west of the Miami 
River and south of Sycamore Street. 

The conductor and the front brakeman continued to walk along the forward portion 
of the train passing the first "Dangerous" tank car (12th). When they reached the 27th 
car, the northernmost standing car in the forward portion of the train, the conductor 
obtained the car number and, referrir^ to the train profile, assumed that the other 
remaining "Dangerous" tank car (30th) was involved in the derailment. During this time 
the car numbers of the standing cars were radioed to the dispatcher as the conductor 
walked toward the south end of the bridge to get additional car information. 

Shortly afterward, the conductor approached south of the bridge and met the 
emergency responders. The conductor advised the emergency responders that "the car on 
fire was filled with yellow phosphorus which is a poison," and further added that the 
immediate area should be evacuated. At this time, the intense smoke and heat prevented 
identification of other cars south of the bridge. The conductor advised that he had the 
train profile, and the responders requested that he accompany them to the command post. 
Before leaving with the conductor, the responders noted that within the few minutes they 
had been observing the accident, the fire in the 30th ear had grown and was spilling out of 
the tank car from a hole in the tank bottom creating an extensive cloud of smoke which 
was drifting east over Miamisburg. 

While en route to the scene, the firechief of the Miamisburg Fire Department was 
advised that the conductor had identified the burning material from the tank car as 
phosphorus. The firechief ordered an immediate evacuation of the west side of the Great 
Miami River. Later, after seeing the direction and size of the cloud, he ordered an 
evacuation of the northeast section of Miamisburg, approximately 1/3 of the city. 

A command post was established approximately 1/4-mile south of the Bear Creek 
Bridge (on Sycamore Street). At the command post, the conductor provided the firechief 
preliminary information from the train profile on the materials being transported. The 
fire department, because of training previously provided by the B&O, expected more 
information than the conductor provided and requested all information that was carried on 
the train. The conductor returned to the locomotive, collected the scattered waybills 
that had fallen to the floor of the locomotive during the derailment, and returned to the 
command post with the waybills. A "Canadian Emergency Response Form for Special 
Commodity PHOSPHORUS" 7/ (see appendix F) that included the shipper's 24-hour 
emergency telephone number, was not among the waybills provided to the firechief at the 
command post. Because the train's crewmembers had not determined the status of the 
cars at the rear of the train, the conductor was unable to provide accurate information on 
the cars involved in the derailment or on the materials contained in the derailed cars. To 



6/ The Chesapeake and Ohio Railway Company. 

7/ On shipments originating in Canada, Canadian law prescribes a specific form of 
emergency response documentation to accompany the waybills for hazardous materials 
moving by rail. According to a representative of CSX, the CSX/Association of American 
Railroads (AAR) emergency guidance for phosphorus was not made a part of the papers 
carried on this train to avoid any confusion that might result from having both the 
Canadian and the CSX/AAR emergency guidance for phosphorus. 



-6- 

obtain the necessary information, firefighters, in full protective equipment, entered the 
derailment site to document the derailed cars and obtain the numbers of the cars 
immediately to the south and north of the bridge. 

During this time, the B&O assistant chief dispatcher contacted the trainmaster who, 
having overheard the radio conversation between the conductor and the B&O Dayton 
dispatcher, was already en route to the site. When the trainmaster arrived at 5 p.m., he 
observed the general derailment area and the "spilled materials flowing into the Bear 
Creek." The trainmaster went to the command post and assisted the conductor in his 
review of the train profile and waybills to confirm the dangerous commodities that might 
have been involved in the derailment. Following this review, the conductor advised the 
firechief that the tank cars involved in the derailment contained phosphorus, sulfur, and 
tallow. 

After reviewing the train consist and waybills with the public safety officials, the 
trainmaster contacted his dispatcher to notify appropriate subcontractors for wreckage 
clearing and chemical cleanup. Additionally, the trainmaster had his dispatcher contact 
the Chemical Transportation Emergency Response Center (CHEMTREC) 8/ and obtain 
guidance for handling phosphorus. According to the trainmaster, he met with the 
firechief around 6 p.m. and based on information obtained from CHEMTREC, he advised 
the firechief "not to use water to fight the fire since they could not flood the phosphorus 
with water and spraying would not put it out." Additionally, the trainmaster stated that 
he advised the firechief that B&O intended to begin removing the rail cars to permit 
access to the site. According to the firechief, he did not have this conversation with the 
trainmaster. 

Among the hazardous materials emergency response guidelines available to the 
firechief on scene were the 1980 and 1984 editions of the U.S. Department of 
Transportation (DOT) Emergency Guide for Hazardous Materials (DOT guide) and the 
National Fire Protection Association's (NFPA) "Hazardous Chemicals Data." (See 
appendix F.) Guide No. 38 of the 1980 DOT guide advised isolating the hazardous area, 
denying entry, and flooding the area with water to cool the containers exposed to flames. 
It also advised wearing self-contained breathing apparatus and full protective 
clothing. 9/ Guide No. 49 of the NFPA guide indicated that when a mixture of sulfur and 
yellow phosphorus is warmed, the two elements unite with vivid combustion and a 
powerful explosion. The NFPA guide also advised deluging with water, taking care not to 
scatter the fire, until it is extinguished and the phosphorus has solidified. Further, this 
guide advised that it then should be covered with water. 

Various fire units and representatives from State agencies began arriving on scene 
during the evacuation. The firechief consulted with other firechiefs who had responded to 
the site to obtain their recommendations on what emergency response tactics should be 
used. Assisting the Miamisburg Fire Department were 14 fire departments from nearby 



8/ The Chemical Transportation Emergency Center of the Chemical Manufacturers 
Association maintains a 24 -hour hotline for emergency information and shipper contacts 
for hazardous material transportation emergencies. 

9/ Since 1980 the DOT has made significant changes to the 1980 guide which are 
reflected in the 1984 DOT Guide. The 1984 DOT guide advises among other things to 
isolate the hazard area and deny entry, to use water spray or fog for large phosphorus 
fires, to not scatter material with more water than is needed for fire control, and to use 
water spray to reduce vapors. 



-7- 



eommunities and a regional hazardous materials response team. Additionally, the 
Director of the Miami Valley Disaster Services Authority (MVDSA) assisted in establishing 
communications and coordinated the activities of the responders. 

The firechief wanted to keep all personnel, including railroad personnel, out of the 
fire area until the fire was under control. The firechief considered the firefighting 
tactics suggested by the other firechiefs. Because of limited access to the site and 
because water cannons with direct hose streams were the only available apparatus capable 
of reaching the burning cars, the firechief said that he had no choice at the time but to 
fight the fire at a distance using direct hose streams. The trainmaster challenged the 
authority of the city and the firechief to handle the emergency; he was escorted from the 
command post under threat of arrest. 

Fire engines were moved into position to draft water from Bear Creek and the Great 
Miami River. About 7:10 p.m., the attack began and approximately 3,500 gallons of water 
per minute were flowing on to the fire. Because of the DOT guidance that said to avoid 
the acid fumes, 15-person crews rotated shifted at the four water cannons that deluged 
the phosphorus tank and spill area. Because of the intense fire and the warnings about the 
possibility of an explosion and the formation of a highly toxic gas if the spilled phosphorus 
and sulfur reacted, 10^/ the firechief ordered all other personnel out of the area. During 
this operation, additional unknown amounts of phosphorus, sulfur, and tallow were carried 
into the creek by the water used to deluge the tank cars. Later, to minimize the release 
of pollutant runoff from the hose streams into the Great Miami River, a containment 
boom was placed across the Bear Creek. 

While the fire department worked to extinguish the flames, other local agencies 
coordinated the evacuation of sections of Miamisburg, West Carrollton, and Moraine. 
When the previously initiated evacuation was completed, an estimated 7,000 persons, 
mostly from the residential district north of Central Avenue in Miamisburg, were 
evacuated. 

Around 8 p.m. the fire from the phosphorus tank car was no longer apparent, but 
smoke and flareups continued in the immediate area at the south end of the bridge; 
commodities on other derailed cars were still burning out of reach of hose streams being 
used at that time. By 8:26 p.m. smoke was no longer emitting from the phosphorus tank 
car. With the fire under relative control, the firechief allowed B&O personnel to begin 
removing the standing cars on the north side of the bridge. While Safety Board 
investigators could not determine the specific details of the conversation between the 
firechief and B&O officials, the firechief later said that the believed that B&O had 
advised that "the sulfur tank car was still on the tracks on the north side of the bridge and 
an engine was sent down [from Moraine] to transport the sulfur tank car to Dayton." 11/ 

Later in the evening, emergency specialists representing the shipper, the carrier, 
subcontractors, and State and Federal agencies arrived in Miamisburg. The firechief met 
with these representatives and used the information they provided over the next several 
days to make decisions during the emergency. 



10 / The NFPA guide warned about the possibility of an explosion, while a local chemist 
warned about the possibility of an explosion and/or the possible formation of a deadly gas, 
phosphorus pentasulfide. 

11 / Actually there was an empty tank ear, the 43rd car, which was on the north side of 
the bridge and at the rear of the train. 



-8- 

Shortly after midnight, a B&O evaluation team was allowed to enter the fire scene 
to assess the extent of damage to the phosphorus tank car (30th) and to determine the 
amount of phosphorus remaining. During these operations, the B&O confirmed that the 
sulfur car (33rd), in fact, was on the bridge. This information was provided to the 
firechief about midnight during an organizational meeting called by the firechief. The 
evaluation team determined that there appeared to be two holes on the top and an 8 -inch 
hole in the bottom of the phosphorus tank car (30th); they estimated about 4,000 gallons 
of product remained inside the burning car. 

During the first and second day of the emergency, several proposals for handling the 
emergency relative to the phosphorus tank car were evaluated during meetings at the 
command post. 

Direct Hose Stream Attack. — The B&O and later, on the second day, the Ohio 
Environmental Protection Agency (EPA) recommended that since the fire from the 
phosphorus had abated, the direct hose streams should be shut off and a mist be used to 
control the smoke from the tank car. After several attempts to remove the firehoses 
briefly, the tank car fire began to rebuild in intensity. Additionally, the B&O advised that 
the phosphorus tank car was perched on an embankment that was being eroded by the 
heavy discharge of water. The firechief was aware that a second flareup was possible if 
the tank car moved, but B&O specialists advised him that the tank car likely would not 
move. The firechief said that he was unable to move misting apparatus close enough to 
the tank car to apply a water mist. For this reason, the firechief could not comply with 
the recommendation, and he ordered continued use of the hose streams to deluge the 
phosphorus tank car, but he reduced the rate of water flow during the first night. 

Plugging. — The B&O initially believed that if the holes in the phosphorus tank car 
could be plugged, the fire could be extinguished. However, this tactic was not feasible 
mainly because of the large bottom hole in the tanks shell. 

Water Flooding of the Interior of the Phosphorus Tank Car. — The B&O believed that 
if the tank car was repositioned so that the bottom hole was well above the liquid level, a 
blanket of water could be injected and possibly smother the fire or seal the remaining 
phosphorus inside the tank car. However, after several attempts to add water, response 
personnel saw liquid phosphorus flowing from the top washout nozzle and small shell holes 
causing the fire to intensify. 

Apply Foam. — Tank car specialists recommended that to exclude air from the 
phosphorus tank car, the car should be covered with a new and improved foam. This plan 
was never attempted because the fire in the tank car intensified before the foam arrived. 

Burial. — Burial was tentatively discussed as an alternate approach should the other 
methods fail. However, this plan could not be attempted until the fire subsided because 
to exclude air from the phosphorus tank car, it would have to be moved to a deep pit 
excavation and covered with sand. 

On July 9, 800 residents were still prohibited from returning to their homes in the 
immediate area of the derailment. At 6:05 p.m. a concrete structure, 12/ not a part of 
the bridge, that had been supporting the phosphorus tank car sank approximately 1.5 feet 
due to erosion caused by the large volume of water directed on to the car. As a result, 



12/ The concrete structure was identified by CSX as a preexisting structure whose 
purpose is unknown. 



-9- 



the tank car tilted about 15° to the north and a large amount of molten phosphorus inside 
the tank car shifted and apparently escaped through the hole in the washout. The fire 
intensified and released a thick, massive smoke plume. The firechief decided that the fire 
was beyond control; thus, the hose streams were directed onto the tank car to cool the 
metal to prevent a massive breakup and thus intensity the fire. 

As winds shifted, the large smoke plume was carried east at 6 mph over Miamisburg. 
Later in the evening on July 9 as the wind subsided, a weather inversion developed causing 
the cloud to remain close to the ground. The city and surrounding jurisdictions initiated a 
second major evacuation affecting an estimated 30,000 persons. 13^/ The evacuated areas 
included Miamisburg, West Carrollton, Moraine, Miami Township, and parts of Washington 
Township. Police departments from 53 jurisdictions assisted in the evacuation of the city 
and surrounding areas; 12 shelters were opened near Dayton, Ohio. 

On July 10, with the prevailing winds at 5 to 10 mph from the south at 135°, the 
plume was fairly dense and low to the ground. An environmental monitoring station 
1 mile northwest of the tank car measured 5.0 mg/m3 of phosphorus aerosol which 
exceeded the threshold limit of 0.1 mg/m3. 14/ 

During meetings at the command post on July 10, proposals were discussed to 
dispose of the estimated 1,000 gallons of phosphorus remaining in the tank car. 

Open Manhole. — It was estimated that if air was blown directly into the tank car, 
the burn rate of the phosphorus would accelerate and consume the remaining 1,000 gallons 
in about 12 hours. To accomplish this, the manhole cover bolts would have to be removed 
by cutting, an air blower would have to be put in position, and a 6 -inch fan duct would 
have to be inserted through the manhole to enhance the burn rate. 

Explosive Demolition. — The EPA proposed that explosive demolition be used to blow 
a hole in the car to accelerate the burn rate It believed that this method would be safer 
than opening the manhole. 

The firechief, in consultation with the city manager, decided to proceed with the 
accelerated burning through the opened manhole because he believed it to be a more 
controllable process. The rate of interior burning increased when the liquid surface was 
exposed to the increased volume of air. On July 11 the intensity of the fire was reduced 
sufficiently and the phosphorus tank car was moved 35 feet to a level position. After 
24 hours, the rate of burning decreased sufficiently to allow further inspection of the tank 
car. It was found that 4 inches of phosphorus residue was "crackling and bubbling" in the 
bottom of the tank car. Water was poured over the remaining phosphorus to extinguish 
the fire. The car was then pulled 60 feet to a bed of sand where it was cut open. The 
remaining product was loaded into drums for disposal. The evacuation order was lifted on 
July 12, 5 days following the derailment. 

To minimize environmental pollution, the area of Bear Creek between the bridge 
and the Great Miami River was isolated by a barrier dam from July 9 through July 11 and 
diverted to the north around an area adjacent to the derailment. Approximately 
200,000 gallons of water per day were treated for several weeks with hydrogen peroxide 



13/ This was reportedly the most extensive evacuation in the United States following a 
hazardous materials railroad accident. 

14 / The threshold limit is the time-weighted average concentration for a normal 8-hour 
workday and a 40 -hour workweek, to which nearly all workers may be repeatedly exposed 
day after day without adverse effects. 



-10- 



to neutralize the phosphorus. The water was then filtered through a sandbed before being 
discharged to the municipal sewage treatment facility. In addition to water treatment, 
the contaminated soils from the creekbed and railbed were excavated to a depth of 12 to 
13 feet. The contaminated soils were placed on an asphalt pad to aerate and mix with 
hydrogen peroxide. After the soils were treated, they were disposed of at a landfill. 
Approximately 5,000 cubic yards of contaminated soil were removed over 2 months. 



Injuries to Persons 



Response 
Crew members Personnel Others Total 












13 
13 


556 
556 


569 
569 



Fatal 

Nonfatal 

Total 

Local hospitals received 569 patient visits 15/ including 27 patients who were 
hospitalized with complaints relating to the spill; specifically, shortness of breath, burning 
eyes, and throat irritation. Ten emergency responders were treated for heat exhaustion 
and inhalation complaints. One firefighter received phosphorus burns on his leg, and two 
others received minor ankle and head injuries. 

Damage 

Damage was estimated by CSX as follows: 

Track $ 10,000 

Bridge str uc ture 175,000 

Signal 3,000 

Rail equipment 242 , 000 

Cargo 630,000 

Civilian response 480,000 
Environmental cleanup 2,000,000 

Total $3,540,000 

This loss estimate does not include costs to evacuees, community disruption, or business 
interruptions. 

Meteorological Information 

The following average weather conditions were observed at the J.M. Cox 
International Airport, Dayton, Ohio, 18 miles from Miamisburg, Ohio. From 3 p.m. until 
8 p.m. on July 8, 1986, the sky was scattered to overcast with 5 to 6 mile visibility with 
thunderstorms and light rain (.6 inches); the average temperature was 87° F, dewpoint was 
71° F, and the wind was from the southwest at 11 knots. 

On July 9, the wind shifted from the southwest to northwest at 7 to 10 knots; there 
was haze with fog in the evening, and the sky was overcast. From July 10 through 
July 12, the wind was mostly from the southeast with periods of rain showers and the 
temperature was in the 70s. 



15/ Ohio Department of Health Report— "Miamisburg Hazardous Material Incident: 
Emergency Room Study," (860726), June 29, 1987. 



-11- 



Emergeney Preparedness 

On April 14, 1986, the B6cO conducted a training session with the Miamisburg Fire 
Department covering B&O procedures for obtaining hazardous materials assistance and 
covering information the traincrew will provide in the event of a derailment. Also, the 
B6cO conducted similar sessions with other fire departments in the area during this time. 

In large part, initial training was provided from programs sponsored by local 
industries, the railroads, and other organizations. This training, which totaled 20 hours, 
included identifying hazardous materials, recognizing and dealing with explosives, dealing 
with railroad emergencies, and introducing the trainees to specialized hazardous materials 
equipment. The sources of this training were the Dayton Police Department Bomb Squad, 
the Ohio State Fire Marshal's Office, the Chessie System, the Detroit, Toledo and Ironton 
Railroads, and an NFPA-DOT slide program. 

During April 1982, six members of the response teams, members of the Dayton Fire 
Department, Huber Heights Fire Department, Kettering Fire Department, and the 
Washington Township Fire Department were sent to the Colorado Training Institute for 
Hazardous Materials to attend an 80-hour in-depth and hands-on program. After they 
returned from the school, the MVDSA prepared a comprehensive training program for the 
other members of the response team; the program was prepared and conducted through 
the end of August 1982. This phase of training totaled some 50 hours of both classroom 
and practical instruction. It covered the following areas: a refresher course on the proper 
procedures for identifying hazardous materials; chemical properties of hazardous 
materials; specialized equipment use and maintenance; containment procedures i.e., 
plugging, patching, diking, etc.; hazardous material tactical considerations; evacuation 
procedures; and decontamination procedures. The MVDSA conducts about 20 exercises a 
year. In August 1984 MVDSA conducted a full-scale exercise involving over 20,000 
participants. 

Product Information 

Yellow Phosphorus. — Yellow phosphorus appears as a pale yellow waxy solid at room 
temperature with a sharp pungent odor resembling garlic. Yellow phosphorus does not 
react with water and is stable as long as it is kept submerged or otherwise excluded from 
air. On exposure to air, phosphorus will begin to heat and smolder, and on reaching 86° F, 
it ignites. Consequently, phosphorus is transported in insulated tank cars in molten form 
for ease of unloading and under a thick layer of water to prevent exposure to air. Burning 
phosphorus produces irritating and toxic combustion products, which may include 
orthophosphoric acid fumes and phosphorus pentoxide, both are hazardous materials 
classified as corrosive. Under U.S. hazardous materials regulation, yellow phosphorus is 
classified as a "flammable solid;" 16/ under Canadian regulations, yellow phosphorus is 
classified as "spontaneously combustible." 

On June 23, 1986, Tenneco Canada, Inc., (ERCO Industries, Ltd.) loaded UTLX 79499 
at Varennes, Quebec, with 176,798 pounds (approximately 12,000 gallons) of yellow 
phosphorus at approximately 130° F and covered it with 25 inches of water. When the 
tank car was shipped on June 27, 1986, ERCO furnished the Canadian National Railways a 
certified bill of lading, the required Canadian Emergency Response Form, Plan 



16/ Under 49 CFR 173.150, a "flammable solid" is any solid material, other than one 
classified as an explosive, which can be ignited readily and when ignited, burns so 
vigorously and persistently as to create a serious transportation hazard. Included in this 
class are spontaneously combustible materials. 



-12- 

No. ERP2-001 (see appendix F), and ERCO's emergency phone number. The Canadian 
National Railways prepared the waybill to accompany this shipment to its destination at 
Albright and Wilson, Inc., in Fernald, Ohio. The waybill described the shipment as 
"Phosphorus, white or yellow, in water, spontaneously combustible 4.2(6. 1)(9. 2) 17/ 
UN1381 Package Group I RQ." The Canadian National Railways added to the waybill the 
required "Dangerous" placard endorsement (as stipulated under 49 CFR Sections 174.25, 
and 174.83 through 174.93) along with the "Poison" endorsement which indicated that 
special handling was required, and assigned Standard Transportation Commodity code 
(STCC) 4916141 18/ to the shipment. The crewmembers of train SLFR were provided, in 
addition to the waybill, the Emergency Response Plan No. ERP2-001. 

CSX stated that at the time of the Miamisburg derailment, the normal CSX practice 
was to enclose a document entitled "Emergency Handling Precautions" for that particular 
commodity and the waybill covering and accompanying a shipment of certain hazardous 
substances. (See appendix F.) This document describes the basic characteristics of a 
substance and emergency measures for handling spills, fires, etc. The same information is 
maintained within the CSX computerized data system and can be accessed via terminals 
located in CSX offices throughout the railroad includir^ those of dispatchers. The 
document is generally placed with the waybill at the time the bill is prepared or when the 
waybill is received with the car in interchange from another carrier. However, when the 
CSX receives a Canadian-origin car, the Canadian Emergency Response Form or Plan for 
the particular commodity is retained with the waybill in lieu of adding CSX's emergency 
handling precautions form. This practice is followed in order to avoid possible confusion 
that may occur by having two sets of guides covering the same equipment. 

Sulfur. — Molten sulfur is sulfur that has been maintained above 245° F and can 
present toxic hazards either due to the release of entrained hydrogen sulfide, a toxic 
flammable gas, or due to the release of sulfur dioxide, a product of combustion. Sulfur is 
not regulated for rail transport and does not require the identification of the hazard class 
and packaging in transportation under 49 CFR Part 172. 

Marathon Oil loaded UTLX 76486 with 197,840 pounds or approximately 
13,000 gallons of molten sulfur, and the tank car was shipped on July 2, 1986, from 
Detroit, Michigan, en route to Dupont, at Fort Miami, Ohio. 

The Safety Board previously has directed the DOT's attention to the necessity for 
classifying and regulating sulfur and other molten materials. Based on its findings on the 
hazards of molten sulfur as a result of its investigation of a January 19, 1985, highway 
accident at Benicia, California, the Safety Board recommended the DOT's Research and 
Special Programs Administration (RSPA): 

1-85-19 

Regulate molten sulfur and, as appropriate, other molten materials as 
hazardous materials, prescribe packaging and handling standards, and 
incorporate information relating to the hazards of these materials into 
warning devices and publications available to emergency responders and 
others involved in the transportation of molten materials. 



17/ Under the Canadian hazard classification system the primary (4.2) as well as the 

subsidiary classification (6.1 and 9.20) are required on the waybill; i.e., primary hazard is 

"spontaneously combustible," and subsidiary hazards, are "toxic" and "hazardous to the 

environment." 

18/ STCC numbers are seven-digit numbers identifying a specific hazardous materials as 

indexed in the STCC of Hazardous Materials of the AAR. 



-13- 

1-85-20 

Classify as priority action the proposed rulemaking in Docket HM-178 
regarding the definition of flammable solid, and establish a timetable for 
its completion. Include in the final rule test requirements and clear, 
objective criteria for shippers to identify those materials included in this 
hazard class. 

RSPA concurred in the Safety Board's assessment that molten sulfur should be 
regulated, and on November 21, 1986, it published a rulemaking (Docket HM-198) 
proposing to regulate as hazardous materials sulfur and other molten materials. 
Additionally, on May 5, 1987, under separate rulemaking (Docket HM-181— comments due 
November 2, 1987) RSPA is proposing the adoption of the United Nations classification for 
sulfur as "spontaneously combustible." Under Docket HM-198 rulemaking actions, RSPA 
sought information on other molten materials that potentially posed hazards sufficient for 
the DOT'S regulation and sought comments relative to the extent such materials should be 
regulated. The Safety Board responded to the HM-198 rulemaking proposal by providing 
information on additional accidents where nonregulated molten materials posed hazards, 
and advised the DOT that in assessing the need to regulate molten materials, the DOT 
should consider the hazards posed by these materials within the various transportation 
environments. For rail transportation, the Safety Board advised that the hazards 
presented by the potential chemical interaction between sulfur and other materials also 
should be evaluated, and it urged the DOT to match the probable consequences of a 
molten material accident with the necessary safeguards. 

Tank Car Information 

UTLX 79499. — This tank car was a 12,500 -gallon, DOT specification 103 W tank car 
built by UTLX in June 1966. It was specifically designed to transport phosphorus. The car 
was equipped with 100 -ton trucks, type E top- and bottom-shelf couplers, and exterior 
heater coils. It was insulated with 4 inches of fiberglass protected by a 1/8 -inch -thick 
steel jacket. The car was 39 feet 4 1/2 inches long and its lightweight was 69,000 pounds. 
The tank had an inside diameter of 98 inches, an inside length of 33 feet 8 1/2 inches and 
was fabricated from American Society for Testing Materials (ASTM) A285 Grade C steel. 
The tank head and shell thicknesses were 1/2 inch. The tank had a 20-inch manway 
entrance, one 2 -inch water induction pipe, one 2 -inch phosphorous loading /unloading line, 
one safety relief valve, and two 10 -inch top washout fittings. The car was equipped with 
body-hung brakes 19/ with the brake cylinder and AB valve reservoir attached to two 6- 
inch-diameter schedule 80 pipes welded directly to the tank shell. 

The 2 -inch water induction pipe on UTLX 79499 was open, and the B-end top 
washout nozzle and the tank shell adjacent to the airbrake support pipe were breached 
during the derailment and subsequent fire. Also, the trailing B-end head received an 
L-shaped tear at the 3 o'clock position which was 1 1/2 by 3/4 inches with less than 
1/8 inch separation in the metal. (See figure 3.) 

During the derailment, the leading truck of the tank car hit the south headwall, 
disengaging the trucks and forcing the lead truck under the center of the car. As the tank 
car detrucked, the underside attachments of the car were subjected to impact forces in a 
rearward direction (from the A-end to the B-end) as it slid over debris. These forces, 
when applied through one of the cylindrical brake supports, generated sufficient bending 



19/ Refers to the practice on early design stub-sill tank cars of attaching airbrake 
equipment directly to the tank shell at the bottom. 



-14- 



a; 



-15- 



moments in the tank shell at the bottom of the tank to tear an 8 -inch -diameter hole in 
the tank shell at the brake support attachment. Next, with the trailing end of the tank 
car elevated and with the car still in an upright position, a passing car struck the body 
bolster and trailing tank head puncturing a hole in the trailing B-end head at the 3 o'clock 
position as viewed from the B-end of the tank car. The tank car then rotated 
counter-clockwise, came off the bridge, and stopped abruptly at the south end of the 
bridge. 

A 2-inch water induction pipe in the dome was found open with the plug valve 
missing. There was fire damage to 3/4 inch of the thread at the end of the pipe. Also the 
B-end washout, which was 10 inches in diameter and 6 inches in height, was damaged over 
1/3 of its area. 

UTLX 79499 was one of 32 similar DOT 103 tank cars built by UTLX for phosphorus 
service and manufactured to the earliest stub-sill 20/ design in which the brake supports 
were welded directly to the underside of the tank. In addition to UTLX 79499, Albright 
and Wilson, Inc., operates four other tank cars that carry phosphorus. Two of these tank 
cars were built by UTLX using the stub-sill design with body-hung brakes. The other two 
were built by General American Transportation Corporation (GATX) which incorporated a 
full-length center sill to which the airbrakes were attached. Following this accident, 
UTLX notified lessees of similar UTLX 103 tank cars with the stub-sill design regarding 
the Miamisburg incident, and many of these cars including those belonging to Albright and 
Wilson have been voluntarily removed from service and returned for modification. After 
learning of the Miamisburg accident, the Canadian Transport Commission (CTC) inspected 
tank cars in Canada and found two similar UTLX tank cars in Canadian service. The CTC 
ordered both of these cars taken out of service. While the Federal Railroad 
Administration (FRA) has inspected similar cars in service, it has not required any to be 
taken out of service nor does it intend to order any modification of similarly equipped 
tank cars. Rather, it intends to monitor an industry-wide retrofit program being 
developed by the Association of American Railroads (AAR) for unprotected body-hung 
brakes. 

UTLX 76486. — This tank car was a 13,300 -gallon, DOT specification 111A100W4 
tank car built by UTLX in 1974 specifically designed for transporting molten sulfur. The 
car was equipped with 100 -ton trucks, type-F 21/ couplers and exterior heater coils. It 
was insulated with 6 inches of fiberglass protected by a 1/8 -inch -thick steel jacket. The 
car was 43 feet 10 inches long and had a lightweight of 63,000 pounds. The tank had an 
outside diameter of 101 inches and was fabricated from ASTM A515 Grade 70 steeL The 
tank head was fabricated of 15/32 -inch -thick steel, and the shell was fabricated of 
7 /1 6 -inch -thick steeL The car was equipped with a stub-sill with the airbrake cylinder 
attached to the stub-sill reinforcing pad. 

Examination of UTLX 76486 disclosed that it had received three end punctures: the 
trailing head had a 2 -foot -long fracture directly above the stub -sill, and the leading head 
had a 10 -inch -diameter and a 28-inch long fracture. Its couplers and draft gears were 
separated from the tank car while derailing. Nearly 50 percent of the outside jacket and 
insulation of the tank car had been burned off. 



20/ A short longitudinal structural member of a car underframe designed to 
accommodate the coupler and draft gear and to transmit coupler forces to the car body on 
cars designed with no through center sill. 

21/ The type-F coupler was developed for general freight service and has the interlocking 
or bottom-shelf feature that restricts vertical motion, thus resisting telescoping and 
jackknifing in the event of a derailment. 



-16- 

UTLX 77400. — This tank car was a 22,000-gallon DOT specification 111A100W3 
stub-sill tank car built by UTLX in 1969. It initially had been designed to transport 
asphalt. The car was equipped with 100 -ton trucks, type-E top- and bottom-shelf 
couplers, and exterior heater coils. It was insulated with 4 inches of fiberglass protected 
by a 1.8-inch-thick steel jacket. The car was 51 feet 3 inches long, and its lightweight 
was 75,600 pounds. The tank had an inside diameter of 113 inches and was fabricated of 
ASTM A515 Grade 70 steel. The tank head was fabricated of 1/2 -inch -thick steel, and 
the shell was fabricated of 15/32 -inch -thick steel. The airbrake equipment was mounted 
on the draft sill. Examination of UTLX 77400 disclosed a hole puncture in the bottom 
center of the tank head on the leading end, and the trailing coupler was broken at the 
bottom knuckle pinhole. 

Protection of Attachments. — Tank car manufacturers began to build stub -sill tank 
cars of the type involved in this accident during the early 1960s. The stub-sill designed 
for tank cars eliminated the full-length center sill beneath the tank previously used to 
withstand the forces imposed by trailing loads and to absorb train draft and buff forces 
generated during train operations not absorbed by the cushioning devices in the stub sill. 
This design change also resulted in many of the attachments, 22^/ once made to the center 
sill, including the airbrake cylinder and reservoir, being relocated and attached to the 
tank. For several years at least three tank car manufacturers used a design attaching the 
airbrake equipment supports directly to the tank car shell. After the cars were in service 
for several years, it was noted that when a force was applied to an appurtenance as 
happens during a derailment, the attachment would generate a bending moment into the 
tank shell that could cause the shell to tear open. 

In 1969 due to industry efforts to improve the performance of tank cars in 
derailments, the AAR Tank Car Committee (see appendix D) required reinforcing pads 
between the attachment and the tank shell. These pads were required to be at least 
1/4 inch thick and to have a breakaway design capability. Concurrently, the subject of 
impacts on tank shells and various appurtenances including tank fittings and attachments 
for the various tank cars came under AAR study. The AAR also petitioned the FRA to 
require similar protection for attachments on new tank cars tanks. In 1971 the FRA 
changed its regulations on attachments as petitioned by the AAR, applicable only to new 
tank cars built after 1971. In effect, more than 4,000 tank cars with brake equipment 
supports directly welded to the tank were "grandfathered" by these requirements and were 
allowed to remain in service unaltered. 

In 1972 the Railroad Tank Car Safety Research and Test Project (Project), Railway 
Progress Institute 23/ (RPI)-AAR cooperative program, completed its assessment of the 
behavior of tank car tanks and their appurtenances in the mechanical environmental of 
accidents. 24/ Its findings, based on a review of 1965 through 1970 accident data, showed 
that when bottom discontinuities were struck, they acted as levers and tore the bottom of 
the tank shell. While these data indicated that bottom fittings and attachments both were 
vulnerable during derailments, the project found that the failure of bottom fittings 



22 / Appurtenances attached to the tank shell and heads which are not associated with 
openings through the vessel wall are tank attachments. Appurtenances attached to the 
tank shell that are associated with openings through the vessel wall are tank fittings and 
included items such as bottom outlets and washout gauging devices, top unloading nozzles, 
and relief valves. 

23 / Railway Progress Institute is an association of railcar and component manufacturers. 
24/ RPI-AAR Final Phase 09, "Report on Tanks, Fittings, and Attachments in the 
Mechanical Environment of Accidents," February 15, 1972. 



-17- 

accounted for the greater number of material releases from tank cars. The project's 
assessment confirmed that the brake support bracket problem was primarily due to the 
absence of a reinforcing pad. The project also identified additional considerations 
including the need for local stress relief to compensate for problems that occur when 
welding a bracket that supports a heavy load to the tank shell. These problems were left 
to the car builders to handle, and as a result, the project did not recommend additional 
requirements for design of attachments. It did, however, recommend that the behavior of 
tank car fittings in accidents be docketed by the AAR Tank Car Committee for continued 
study. 

After the tank car manufacturers began following the AAR's requirements for 
installing reinforcement pads, metal fatigue problems were experienced with the 
1/4 -inch -thick airbrake reinforcement pads. All but one car builder used shell plate 
metal for making their pads, consequently the pads were greatly in excess of the 1/4 -inch 
minimum thickness and these pads experienced no problems. The AAR later negotiated 
with the one tank car builder to use pads of equivalent shell-plate thickness. The AAR 
neither repetitioned or otherwise advised the FRA to change its tank car specifications 
nor proposed additional design or fabrication requirements of its own for increasing the 
required reinforcement pad thickness. Rather, the AAR relies on the tank car approval 
process to ascertain that adequate thickness pad is being specified. 

In 1974 the Tank Car Committee of the AAR approved protection specifications for 
bottom outlets, washout, and sumps (discontinuities) for new stub-sill pressure cars 
(classes 112A and 114A and the proposed class 120A). Concurrently, the subject of 
bottom outlets on existing stub-sill tank cars came under study. In 1977 the committee 
developed protection specifications for bottom fittings on new nonpressure stub-sill tank 
cars. As of January 1, 1978, all newly built, low-pressure (less than 100 pounds working 
pressure) stub-sill tank cars have been required to have bottom discontinuity protection if 
the bottom discontinuities extended more than 1 inch. In 1980 the AAR committee 
required protection of bottom discontinuities on existing class 112 and 114 stub-sill tank 
cars used to transport liquefied gas or anhydrous ammonia. To develop a schedule of 
priorities for retrofitting other existing tank cars with bottom discontinuity protection, 
the committee appointed a task force of representatives from the railroads, the 
Compressed Gas Association, the Chemical Manufacturers Association, the RPI, and the 
AAR's Bureau of Explosives (B of E). The task force developed specifications to require 
protection of bottom discontinuities on existing nonpressure, stub-sill tank cars used to 
transport certain hazardous materials as listed in the eight AAR commodity groups. The 
dates by which this protection must be provided were established for each AAR 
commodity group with all protection required to be completed by July 1, 1990. None of 
these protection requirements affected attachments to tank cars. 

In it 1979 report which reviewed the FRA's hazardous materials program 25/ the 
Safety Board recognized the progress made by the AAR for protecting bottom outlets. 
However, because it recognized that the failure of bottom outlets was only one of several 
tank car appurtenance failures capable of releasing hazardous materials from tank cars 
during derailments, on March 20, 1979, the Safety Board recommended to the FRA: 



25 / For more detailed information, read Safety Effectiveness Evaluation— "Review of the 
Federal Railroad Administration Hazardous Materials Program and the Applicable Track 
Safety Standards" (NTSB-SEE-79-2). 



-18- 



R-79-24 

In cooperation with the [ AAR's] Inter -Industry Task Force, determine 
what additional cost effective steps, based on risk-ranking results, can 
be taken to make tank cars more resistive to hazardous materials 
releases in derailments. 

On October 12, 1979, the FRA responded that it was working closely with the AAR/RPl 
Project which was directed at making tank cars more resistant to hazardous materials 
releases in derailments. The Safety Board advised the FRA on May 12, 1980, that its 
response failed to address the specifics of the recommendation. Additionally, the Safety 
Board advised the FRA that Safety Recommendation R-79-24 would be classified as 
"Open— Unacceptable Action" until the FRA provided a response that addresses the 
specifics of the recommendation. 

In its 1980 special investigation report 26/ the Safety Board examined the behavior 
of derailed tank cars equipped with Safety Board-recommended shelf couplers, head 
shields, and thermal coatings and compared their performance with tank cars not so 
equipped. The report concluded that the recommended safety devices were effective in 
minimizing the release of hazardous materials from tank cars so equipped. Further, the 
report concluded that the majority of the breaches in the tank cars resulted from 
damaged tank car appurtenances, primarily top fittings and bottom outlets. 

In conducting its investigation, the Safety Board reviewed the actions being taken by 
both the industry and the FRA. It was determined that the industry had proven the 
technological feasibility for protecting bottom fittings (outlets) and had begun a program 
to do so; however, the protection of top fittings had not received comparable attention 
although the same technology could be applied to them. With respect to the efforts of the 
FRA, the Safety Board determined that the FRA was not obtaining information on the 
breach mechanisms of tank cars during derailments to assess the safety benefits or 
liabilities of the regulations for tank car modification. The Safety "oard also found that 
data being collected by the AAR/RPI on form BE/RA-49-79, "Owners Tank Car Damage 
Report," neither documented the method of product of loss nor the events that caused the 
release. Based on its finding that the FRA had not collected data on the effectiveness of 
tank car protection nor had it documented how tank car product loss occurs in tank car 
accidents on May 8, 1980, the Safety Board recommended to the FRA: 

R-80-14 

Cause data to be collected on tank car derailment behavior to identify 
control methods, and incorporate findings in new car construction. 

On July 18, 1980, the FRA, responding to Safety Recommendation R-79-24, stated 
that it believed that the Inter-Industry Task Force could play a part in the process of 
determining proper modifications to tank cars to reduce the incidence of hazardous 
material releases in derailments. The FRA further advised that it had been working with 
the Project since 1972. The FRA believed the Project was the key body for achieving 
results because the Project, as opposed to the Inter-Industry Task Force, had the required 
knowledge, expertise, and ability to bring about necessary improvements in tank car 
safety. 



26 / For more detailed information, read Special Investigation Report— "The Accident 
Performance of Tank Car Safeguards, March 8, 1980," (NTSB-HZM-80-1). 



-19- 

On August 8, 1980, in response to Safety Recommendation R-80-14, the FRA 
advised the Safety Board that it was researching and testing the mechanisms involved in 
the breaching of tank cars, but it provided no details on these efforts. The Safety Board 
classified this recommendation as "Open— Unacceptable Action" and informed the FRA 
that its reply failed to address the recommendation in that no action was cited relative to 
the FRA's collection and use of data or identifying breach mechanisms. 

In its June 8, 1981, followup letter to the FRA on several recommendations 
including R-79-24, the Safety Board noted that the Inter-Industry Task Force had been 
dissolved. However, before dissolution a System Safety Analysis Subcommittee had been 
established under a cooperative agreement between the AAR and the Chemical 
Manufacturers Association to continue analyzing available rail accident data to make 
certain that the findings from the analyses were translated into increased rail safety. The 
Safety Board acknowledged the FRA's statement that the FRA had been working jointly 
with the Project to develop cost-effective improvements to tank cars and requested the 
FRA to keep the Safety Board informed about progress made. In the interim, the Safety 
Board classified Safety Recommendation R-79-24 as "Open— Acceptable Alternate 
Action." 

On July 14, 1982, in response to Safety Recommendations R-79-24 and R-80-14, the 
FRA advised the Safety Board that the AAR had voluntarily established retrofit 
requirements for bottom outlet protection of all stub-sill tank cars that transport 
hazardous materials. Because of extensive voluntary actions, the FRA advised that it did 
not believe that regulations for bottom valve outlet protection were warranted. The FRA 
further advised that its review of accident data concerning the protecting of top fittings 
did not indicate sufficient justification for further regulations; however, it advised that 
the industry was considering the establishment of limitations of their maximum height. 
The Safety Board evaluated these two actions as a good -faith showing by the FRA that it 
was concerned about the consequences of appurtenance failures and that it was active in 
seeking improvements. Therefore, on October 4, 1982, the Safety Board classified Safety 
Recommendations R-79-24 and R-80-14 as "Closed— Acceptable Action." 

On May 2, 1980, following two accidents involving airbrake attachments, the 
Seaboard Railroad (SBD) (now a part of CSX) requested the AAR to again review the 
accident history of cars with brake support equipment welded directly to the tank shell. 
The SBD reported that as a result of a 21 -car derailment at Buckhead, Georgia,on 
April 19, 1980, the brake equipment of a liquefied petroleum gas (LPG) tank car was torn 
off leaving two holes in the shell about 11 inches in diameter. Immediately following the 
derailment, the LPG burst into flames and burned for 4 days. The SBD investigation 
determined that the use of a reinforcing pad between the tank shell and the brake support 
could have prevented the LPG release and fire. The SBD added that "this situation is no 
different from having bottom outlet broken off in a derailment and should be treated 
similarly." SBD added that in 1973 it experienced an incident in which a tank car lost its 
airbrake support brackets. 

The AAR referred this request to its Tank Car Committee which responded to the 
SBD: 

Union Tank Car Company built 1,842 tank cars between 1963 and 1966 
with similar brake equipment support arrangements and voluntarily 
discontinued using this design. Since there were no AAR or DOT 
requirements prohibiting such arrangements at that time ... it was the 
opinion of the subcommittee that remedial action is not warranted at 



-20- 

this time since a large number of similar tank cars have been in service 
for so many years without experiencing similar damage. The Buckhead 
incident is the only reported puncture associated with this design. 

In 1983, the RPI/AAR Project made an assessment 27/ of the 1965 through 1980 
AAR accident data and found that 20 tank cars had released hazardous materials due to 
attachments failures; 8 of the 20 attachment failures were at brake supports. However, 
the Project again maintained that there had been so few cases where attachment failure 
had been involved that no attempt had been made to examine the damage and design in 
detail in order to estimate if a change would have prevented the tear. 

As a result of the Miamisburg incident, the AAR Tank Car Committee has changed 
its viewpoint in regard to protecting bottom attachments. The committee has now 
required a retrofit of the existing fleet of 3,630 tank cars that were built with unpadded 
body^lung airbrake attachments. Specifically, the committee now has approved proposals 
to modify the tubular brake equipment supports on a product hazard basis, beginning with 
the pressure cars and progressing through the material hazard rankings until, at the end of 
a 5-year-period, the entire group of cars would be modified, down-rated to carry 
nonregulated commodities, or scrapped. The modifications would consist of replacing the 
airbrake support bracket with a pad and new pipe designed to safely break away. The 
committee has also initiated a study of its accident review procedures and a study of the 
Project's 1972 and 1983 reports for possible future activity. 

Development of Tank Car Safety Standards 

Tank car safety problems identified during the Miamisburg accident and in previous 
Safety Board investigations of accidents at Marshville, North Carolina; North Little Rock, 
Arkansas; Elkhart, Indiana; and Seattle, Washington; 28/ and other accidents all combined 
to prompt a Safety Board review of the process by which tank car safety standards have 
been developed and how deficit conditions are identified and corrective actions 
implemented. The Safety Board reviewed the history of tank car development, studied 
the Federal and industry safety standards for tank cars, and formed an investigative group 
consisting of the FRA, the AAR, and the CTC to collect information on the procedures 
used by each agency in formulating safety standards for tank cars. On April 9, 1987, the 
group met to discuss the tank car safety programs and to identify interactions among 
those agencies. Appendix D contains a description of the FRA delegations of authorities 
to the AAR for tank car safety, a description of the present AAR processes for 
implementing these delegations, and a description of the monitoring performed of the 
AAR processes. 

Initial Tank Car Safety Program .— Early development of tank car safety standards 
began when the Interstate Commerce Commission (ICC) was authorized by a 1921 law (41 
Stat. 144) to use the services of the ARR's Bureau for the Safe Transportation of 
Explosives and Other Dangerous Articles (now the B of E) for carrying out its 



27/ RPI-AAR Phase 02, "Report on Analysis Non-Pressure Tank Car Behavior in 
Accidents," March 24, 1983. 

28/ For more detailed information, read Railroad Accident Reports— "Seaboard System 
Railroad Freight Train FERHL Derailment and Fire, Marshville, North Carolina, April 10, 
1984," (NTSB-RAR-85-5); "Hazardous Materials Release, Missouri Pacific Railroad 
Corporation's North Little Rock, Arkansas, Railroad Yard, December 31 1984," 
(NTSB-SIR-85-3); "Anhydrous Hydrogen Release from NAIX 9408, Train No. BNELY3Y at 
Conrail's Receiving Yard, Elkhart, Indiana, February 4, 1985," (NTSB-HZM-85-3). 



-21- 

responsibilities for developing tank car safety standards. A 1979 U.S. Senate 
report, 29/ reviewing and analyzing the DOT's hazardous materials transportation safety 
regulatory program, stated, "The ICC took this Congressional authorization literally; it 
practically turned the hazardous materials transportation safety program, including tank 
car safety standards, over to the AAR's Bureau of Explosives." 

In 1960, the ICC law was amended (Public Law 86-710) by among other changes 
authorizing the ICC to use the services of carrier and shipping associations in its 
hazardous materials safety program. Again, according to the 1979 report, "The ICC took 
this authorization literally, turning to the trade associations particularly in the 
development of the requirements for the larger containers, such as tank cars and tank 
trucks." The report stated that the ICC did not have sufficient expertise to analyze the 
industry recommendations and the ICC did not establish criteria or procedures to guide 
the industry in its development of standards. Generally the ICC accepted without 
question the industry-developed standards. 

FRA Tank Car Safety Program .— In 1966 the U.S. Congress created the DOT and 
transferred to it all safety regulatory authority for the transportation of hazardous 
materials formerly vested in the ICC, the Federal Aviation Administration, and the U.S. 
Coast Guard. However, the delegations of authority to industry organizations and the 
existing industry -oriented framework in which most of the regulations for the 
transportation of hazardous materials had evolved remained essentially unchanged. 

By the time the hazardous materials safety program of the ICC was transferred to 
the DOT, the ICC had delegated hundreds of responsibilities to the AAR, among them the 
responsibility for tank car safety. Responsibility for carrying out the DOT's authority 
over tank car safety was assigned to the FRA, and it continued the delegations of 
authority made by the ICC. The FRA continued to have exclusive responsibility for tank 
car safety standards until July 1975, when the Secretary of Transportation created the 
Materials Transportation Bureau (MTB) 30/ and designated it as the lead agency for the 
DOT's hazardous materials transportation safety program. Its responsibilities now are 
administered by the RSPA. While the MTB was given responsibility for issuing all 
regulations affecting the transportation of hazardous materials, the initiatives for 
developing regulations applicable to a single mode of transportation was left with the 
modal DOT administrations; thus, the FRA continued to be the responsible agency within 
the DOT for rail tank car safety standards. 

Since 1966 RSPA has withdrawn from the AAR and others more than 500 delegations 
of authority; however, the FRA has continued virtually unchanged the delegations of 
authority to the AAR for tank car safety. Like the ICC, the FRA did not establish 
criteria or substantive procedures to guide the AAR in its implementation of the 
delegated authorities. 

The regulations (49 CFR 179 and 173.31) include the DOT's specifications for tank 
cars; delegations to the AAR for approving designs, materials, construction, conversion, 
and alteration of 10 ears; certification requirements; provisions for service trials 31/ of 



29/ Congressional Research Service, Library of Congress, "Hazardous Materials 

Transportation: A Review and Analysis of the Department of Transportation Regulatory 

Program," April 1979. 

30/ The MTB no longer exists. The hazardous materials responsibility previously managed 

by the MTB was made a responsibility of the Office of Hazardous Materials which was a 

suborganization of the MTB. 

31/ These service trials refer to a DOT exemption process and are different from the 

"AAR service trials of values and fittings" that were allowed under the regulations. 



-22- 

tanks and equipment that do not conform to DOT regulations; delegation to the AAR for 
developing recommended changes or additions to the DOT specifications for tank cars; 
and some general actions to be taken by the AAR in carrying out the delegations of 
authority. For example, the car builder must build the car according to the approved 
drawing and follow requisite AAR-specified inspections. The regulation requirements do 
not address matters such as the qualifications or interests represented by persons serving 
on AAR committees that carry out the delegated responsibilities, the procedures or 
analyses to be followed by AAR committees in making determinations about the adequacy 
of designs and modifications approved to meet public safety needs, the documentation 
requirements in support of decisions made, or other procedural matters related to the 
implementation of the delegated authority. The regulations establish only one 
requirement for the AAR to report to the DOT the actions it has taken under the 
delegated authority — to report its recommendations about proposed changes or additions 
to DOT specifications for tank cars. The FRA does not have procedures for monitoring 
the actions taken by the AAR under the delegated authority. 

The Safety Board previously directed the FRA's attention to the fact that neither 
the FRA nor its delegated agent, the AAR, inspects the work of tank car manufacturer's 
to determine if tank cars are being constructed in compliance with DOT regulations and 
AAR Tank Car Specifications. Based on its findings as a result of its investigation of a 
December 31, 1984, ethylene oxide release at North Little Rock, Arkansas, the Safety 
Board recommended that the FRA: 

R-85-99 

Institute an inspection program to verify that tank cars intended to be 
used in hazardous materials service are manufactured in compliance with 
Department of Transportation standards. 

On February 18, 1986, in response to Safety Recommendation R-85-99, the FRA advised 
the Safety Board that it was working on a plan to address the inspection of tank cars 
during their manufacture and that when the plan was complete, it would be provided to 
the Safety Board. On December 2, 1986, the FRA provided a copy of a proposal to 
perform a review of the AAR Tank Car Committee process and of new construction, 
repair, and alteration facilities for tank cars. This proposal included the following list of 
"points to be reviewed," which provides insight into previous actions by the FRA for 
monitoring the activities of the AAR in carrying out the FRA-delegated authorities: 

o Are applications for tank car construction and modification 
complete? 

o Is the review thorough, and is there a procedure or form used as a 
check list to assure that all pertinent information has been 
furnished on the application? 

o How often does the committee meet? 

o How often are AAR-certified shops inspected? 

o How does the Tank Car Committee decide what is to appear on 
their dockets for discussion? 



-23- 



o Is there any procedure established to inform RSPA/FRA of possible 
problems in specific design issues or other matters that would be of 
concern pertaining to safety (i.e., cracking of stub-sills, corrosion, 
etc.)? 

o Who decides when a docket is satisfactorily completed? Is it by 
majority of all voting members? 

o Does one negative vote reject an application, certification, or 
docket issue? 

o How are materials, appurtenances, gaskets, valves, etc., approved? 

o Are outside consultants used in evaluating tank car designs, 
materials, appurtenances, etc.? 

o What criteria are used to nominate committee members? 

o How often are Chairmen chosen and what is the procedure? 

o Is there any mechanism to remove a committee member who is not 
producing satisfactorily? 

As a part of the FRA committee's current actions during 1987, answers to these 
questions are to be obtained by reviewing the AAR's Washington office records and 
procedures, interviewing at least two Tank Car Committee members, inspecting at least 
two tank car manufacturing/repair facilities, and inspecting the procedures used by two 
major tank car builders for submitting to the Tank Car Committee for approval of 
applications for construction of tank cars and for repairs or alterations to tank cars. The 
FRA estimated that this review would be completed the fall of 1987. 

The Safety Board was provided during its review, an August 27, 1986, letter from 
the FRA's chief counsel to the AAR which discussed the nature and scope of the major 
delegations to the AAR Tank Car Committee under the DOT's regulations. 

The Department's authority under the Hazardous Materials 
Transportation Act to "issue regulations for the safe transportation in 
commerce of hazardous materials, 49 U.S.C. §1804," rests with the 
Research and Special Programs Administration. RSPA has delegated 
certain specific functions to the Tank Car Committee, e.g., 49 C.F.R. 
§179.3. 

There are two general characteristics of such delegations. First, any 
action by a delegate acting in that capacity is wholly circumscribed by 
the scope of the delegation. Thus, any act putatively within the 
delegated capacity, but actually outside the scope of the delegation, is 
without legal affect. Second, since delegations are revocable at any 
time, publication of a notice of proposed rulemaking revoking a 
delegation is not required if the delegation is published in the Code of 
Federal Regulations. 

The letter then described the FRA's understandings of the delegated authorities. 



-24- 



It is especially significant that the Department has delegated to the 
Tank Car Committee the responsibility to approve or reject an 
application for the design, materials and construction, conversion or 
alteration of tank car tanks based on the provisions of 49 C.F.R. Part 
179, Specifications for Tank Cars. 

The letter explained that the Tank Car Committee exercises no discretion in the 
referenced approval process since any application in compliance with effective 
regulations and specifications "will be approved" and any applications not in compliance, 
cannot be approved; for these, the committee could only recommend service trials. 

The FRA chief counsel noted that even should the Tank Car Committee approve a 
noncomplying application, this does not permit the person receiving the approval to 
violate the DOT's specifications by issuing a certificate of compliance for a tank car when 
the tank car does not meet the DOT's specifications. The Tank Car Committee's actions 
under the delegated authority were characterized as serving the interests of the DOT in 
using its expertise to screen out noncomplying applications. The letter specifically 
pointed out that a tank car builder may not use the Tank Car Committee's approval to 
operate a tank car that violates DOT specifications, and that the DOT is free to act to 
correct an improper Tank Car Committee approval. 

The FRA's general counsel described other delegations to the Tank Car Committee 
as having the authority "to approve designs or materials other than those specifically 
prescribed by a particular rule." It was noted that "such delegations vest discretion in the 
Tank Car Committee, but only as to the specific subject covered by that Section." 
Additionally, by FRA adoption of appendix R of the AAR Tank Car Manual, repairs and 
alterations of tank cars performed in accordance with appendix R are also governed by 
AAR-developed procedures. 

During the April 9, 1987, meeting conducted by the Safety Board, the FRA advised 
that it currently was reviewing the AAR operations. Other than the present review, the 
FRA monitored AAR under the FRA-delegated authority by reviewing FRA 
accident/incident data; inspecting tank car facilities (begun in 1983); attending AAR Tank 
Car Committee and Hazardous Materials Steering Committee meetings; and 
communicating daily with the AAR both by telephone and through written 
communications regarding a variety of safety issues. However, of the three 
representatives of the FRA attending the April 9, 1987, meeting, none could attest to any 
actions by the FRA for reviewing the records of the AAR or for monitoring the various 
delegated activities carried out by the AAR since 1976, the earliest time any of the three 
had responsibilities for tank car safety. Also, none of the representatives could recall 
written procedures or an FRA policy for monitoring the activities of the AAR as they 
relate to the delegated authorities. Finally, the AAR representative at the April meeting 
could not recall any requests by FRA representatives to review AAR records or to 
monitor the Tank Car Committee activities. 

AAR Tank Car Safety Program. — The Tank Car Committee is the entity in the AAR 
responsible for carrying out the FRA-delegated authorities on tank car safety. The Tank 
Car Committee bases it approvals of tank car designs, modifications, and alterations on 
current DOT and AAR requirements. (See table 1.) The Tank Car Committee also is 
charged with reviewing requests for changes or additions to the specifications for tanks, 
considering the recommendations of its Subcommittee on Specifications, and reporting its 
recommendations to the DOT. (The DOT regulations, as a part of its delegation to the 
AAR, require that the Subcommittee on Specification review proposals for new tank 



-25- 



Table 1.— AAR/TCC Flow Chart - Application for Approval of Tank Car Construction 













Tank Car Builder 










Application 










V 










AAR/TCC 










w 






t 


i 


Tank Car Committee Distribution 

And Review Process 12 Members 

(Excluding RPI Representative) 


i 


a 

Ui 






1 


' 






z 




DOT Requirements 




o 






1 


' 






AAR Requirements 












1 


r 




Signed Certificate of 
Construction That Car 
IVIeets Both AAR & DOT 
Requirements 






AAR 










1 


' 




i 


L 






r 

























-26- 

specifieations and make recommendations to the Tank Car Committee on proposed 
additions and changes. Although incorporated within the requirements of the delegated 
authority, this Subcommittee was abolished in 1972 under a structural reorganization 
effected by the AAR's Director of Technical Committees. The AAR representative 
advised that "this subcommittee had functioned at least since 1956 as the total group of 
interested parties who formulated proposed revisions to the Specifications for Tank Cars 
for review and approval by the Tank Car Committee." The AAR representative added 
that this group is still in place and is now called "Subcommittee 1 and 2, Working Groups" 
and are studying proposals in specialized areas.) 

According to the AAR, members of the Tank Car Committee must have direct 
technical expertise in hazardous materials transportation and are appointed by the 
General Committee of the ARR's Mechanical Division from nominations made by railroads 
and others. (The AAR representatives stated that qualified individuals representing 
general public interests could be appointed; however, such a nominee has never been 
considered.) The AAR now authorizes the Tank Car Committee to have 16 voting 
members (10 from railroads, 1 from RPI, and 5 from chemical manufacturers and tank car 
owners and 1 representative of the AAR's B of E, who is a nonvoting member. This 
organization reflects recent changes of the committee developed to strengthen the 
railroad industry's influence in the tank car standards, to provide railroad industry 
experience on all aspects of tank car safety rather than so ley tank design, and to ensure 
more active participation by the railroad members. The voting members vote "according 
to the dictates of the technical expertise they possess as related to the issue before the 
committee." The AAR's recent changes in this committee's structure also included a 
requirement that the chairman be selected from the railroad membership and added a 
cochairman who also must be selected from the railroad membership. 

The AAR stated that its procedures for the Tank Car Committee are conducted by 
Robert's Rules of Order, agendas for meetings are prepared and distributed, and minutes 
of the meetings are recorded. For items to be considered by the committees, there must 
be a quorum or simple majority of voting members present. Items are approved when a 
majority of members present consent. There are no limitations concerning the number of 
members on the Tank Car Committee who represent the same organization. 

In 1986 and previous years, the Tank Car Committee was authorized to have 13 
voting members any of whom could serve as its chairman. The B of E had a nonvoting 
member. Seven members were required to be selected from railroads, one from the RPI, 
and the remaining five from nonrailroad trade organizations. This organization was 
believed to provide a reasonable balance: the railroads are responsible for the safe 
transportation of hazardous materials and in general are economically responsible for the 
effects of releases; the shippers and owners of tank cars may desire to maximize the 
amount of product that can be transported in tank cars given the gross weight limitations 
imposed by the rail system design; and the tank car builders are responsible for the design 
and manufacture of the tank cars. The AAR representative stated that trends in the 
voting had been noted wherein some of the railroad members were not active in reviewing 
and voting on the 400 to 800 applications that are handled by the Tank Car Committee 
every year by mail. To secure approval by letter ballots 32/ for constructing tank cars on 
a timely basis, AAR staff sometimes had to actively solicit railroad member votes since 
at least one railroad member had to vote for the ballot to represent a majority of the 
votir^ members. Inactivity by the railroad members in voting on these letter ballots 



32 / Tank Car Committee approval of an application by mail requires both a majority vote 
and no negative ballots cast by the members. 



-27- 

could result in an item being approved by members representing chemical manufacturers 
and tank car owners. 

The AAR representative stated that the railroad members are fully informed and 
active in voting on major issues at Tank Car Committee meetings. The representative 
further noted that at meetings when a majority of voters approved an item, but the 
approving votes were not balanced among the varied interests, approval of the item 
normally would be withheld by the direction of the chairman until the proposal could be 
modified and a consensus achieved. 

Safety Board requests made in March 1987 to inspect AAR records as a part of its 
investigation were denied by the AAR. Later, limited access was granted and the AAR 
explained that it had hesitated primarily because no one outside the AAR had ever 
requested to review these records; thus, it had never formulated a policy on allowing 
others to have access to its records. Minutes and other records of the Tank Car 
Committee now are available to qualified Federal government representatives for review; 
however, this policy was only established by the AAR after the Safety Board made its 
March 1987 request. 

The Canadian Transport Commission 

Primary responsibility for railroad tank car safety in Canada is vested in the CTC. 
It, like the FRA, has delegated responsibilities to the AAR Tank Car Committee, tank car 
owners, railroads, shippers, and other organizations such as the Chlorine Institute, 
Canadian Compressed Gas Association, Canadian Fertilizer Institute, and the Propane Gas 
Association. The CTC adopts as its requirements most of the provisions of 49 CFR Part 
179 on tank car specifications; however, for tank cars in Canadian service, it goes beyond 
these requirements by: 

o requiring full head shields on newly built pressure tank cars where 
head protection is required; 

o prohibiting the use of ASTM A515 steel in its present form on any 
newly built tank cars; 

o requiring thermal insulation on cars carrying most of the liquefied 
gases; and 

o requiring an orange colored bank on certain compressed gas tank 
cars to assist in identifying these tanks cars. 

Identification of tank car deficiencies and determinations about safety 
improvements usually occur as a result of accident and incident investigations and as a 
result of independent actions taken by the CTC based on information gained through 
public hearings or information developed on perceived safety threats. Safety 
improvements identified are implemented by ordering retrofits or, when a tank car 
manufacturer is cooperative, by periodically monitoring the progress of voluntary actions 
taken. 

The CTC presently inspects tank car manufacturers infrequently and usually does so 
as a result of accidents or incidents; however, the CTC is formulating a formal program 
for determining that manufacturers comply with its regulations. The CTC advised that its 
interface with the AAR and the FRA was informal and irregular, that the CTC had only 



-28- 



limited access to any AAR records, and that the CTC had never attempted to obtain any 
FRA records officially. However, the CTC representative participating in the Safety 
Board's review of the tank car safety programs expressed the CTC's believe that the 
interface among the CTC, the FRA, and the AAR should be formalized and strengthened 
to identify and resolve common safety problems associated with tank cars. Common 
safety problems cited as requiring coordinated efforts among the three agencies were: 
(1) improving safety relief valves in anhydrous ammonia service; (2) providing 
reinforcement pads on some tank cars; and (3) improving the quality of workmanship in 
some tank car shops. 

In its February 26, 1987, resolution to the CTC, the Canadian Immediate Response 
to Railway Accidents Technical Experts (IRRATE) 33/ supported the view that increased 
cooperation among the CTC, the FRA, and the AAR was necessary for improving tank car 
safety. That resolution called for: 

... a serious attempt to be made to form a joint regulatory group 
between Canadian and U.S. authorities which should review the adequacy 
of the regulations periodically, assess proposals for any regulatory 
changes, and assure that any changes are implemented in the same 
manner and at the same time by the regulatory authorities of Canada 
and the U.S. 

Findings from an investigation on the February 28, 1984, failure of a tank car at a 
railroad yard in Vaughan, Ontario, Canada 34/ greatly influenced the efforts of the CTC 
to formalize a monitoring program for covering the responsibilities of the AAR and 
others. The tank car failure in Ontario resulted from the propagation of a preexisting 
welding-related defect that occurred during the manufacture of the tank car but was not 
detected by tests and inspections performed before the tank car was placed in hazardous 
materials transportation service. Since the failure involved problems potentially related 
to the performance of rail-related industry groups in carrying out delegated 
responsibilities, the investigation also looked at the CTC's regulatory program of CTC and 
at its monitoring of the delegated authorities. 

The investigative effort recognized that Canadian action by itself would not 
effectively provide the measures necessary to ensure public safety. It also recognized 
that many tank cars were in daily use transporting hazardous materials to and from the 
United States and that the CTC with its limited resources likely would be unable to 
effectively monitor delegated activities performed outside of Canada. Consequently, 
CTC concluded that it needed to develop an arrangement with "those in authority, and 
those involved in tank car manufacturing in the United States as well as in Canada in 
order to ensure consistency of control over-border tank car usage." 

Appendix G provides the investigative report discussing the CTC's relationship with 
the AAR. In part this segment of the report concludes: 

Recognition that the performance standards for all safety devices and 
tank car retrofit proposals requires re-evaluation on a cost/benefit/risk 
basis; 



33/ Resolution: Immediate Response to Railway Accidents Technical Experts (IRRATE), 
Item 2-87, February 26, 1987. 

34/ Report of the Inquiry into the Failure of Tank Car UTLX 98646 on February 28, 1984, 
in the Canadian National Railway Company's MacMillan Yard, in the Township of 
Vaughan, Ontario. 



-29- 



Identification that the CTC needs to have liaison with the FRA, the 
AAR, and others whose actions affect tank car safety; 

Recognition that the initiative for tank car safety improvements most 
always rests with the AAR; 

Recognition that there is no contribution to the AAR's deliberations on 
behalf of the Canadian public; 

Identification that resolution of safety problems recognized in Canada 
seem to be left to the AAR Tank Car Committee; 

Documentation that the AAR is a self-regulating agency operating in a 
geographical territory over which no single regulatory body had complete 
jurisdiction, that the AAR performs both coordinating and technical 
functions for assistance both to its members and any other group that 
requires the AAR expertise, and that [the AAR] is able to draw upon a 
substantial body of technical knowledge and expertise; 

Recognition that an AAR standard, on the average, may be acceptable to 
the Tank Car Committee members and to their respective 
'constituencies' but these individuals may or may not always include 
Canadian interests and concerns; 

Identification that a means must be developed for reviewing and 
evaluating AAR standards on behalf of the Canadian public; 

Recognition that by substituting a new formal structure for the present 
ad hoc Canadian surveillance and regulation of design specification 
standards that originate with the AAR will better serve to protect the 
safety of the Canadian public. 

Case History: FRA Oversight of AAR Tank Car Safety Activities 

Early nonpressure stub-sill tank cars manufactured by GATX tended to buckle in the 
shell of the tank as a result of buff forces, the longitudinal forces generated during train 
operations. These tank cars were experiencing localized buckling near the inboard ends of 
the draft sills. If damages occurred during normal operations and the tank car was 
designed and constructed according to AAR standards, the railroads were required to pay 
for the damages incurred. 

In response to an AAR-member railroad report of incidences of tank car buckling, 
the AAR reviewed these incidents and its design standards. The AAR Car Construction 
Standards Committee determined that its 800,000-pound compressive end-load 
criteria 35/ for railroads should be increased and on July 1, 1974, established a 
1,000,000 -pound compressive end-load standard. While the rail industry through the AAR 
did not require tank cars to be modified to the new AAR draft loading standards, at that 
time it was made effective for new and rebuilt status cars and for those car owners who 
wanted protection under the interchange rules for buckling damages. Under interchange 
rules, railroad liability was limited to those cars that were retrofitted to meet the new 
1,000,000-pound draft standard. 

35/ Draft, buff, compressive, and impact loads were all increased at this time. 



-30- 

To comply with this new standard, GATX qualified a design that modified existing 
noncomplying tank cars by longitudinarily attaching to the underside of the tank two 
parallel steel bars located 16 inches apart. (All owners of these tank cars did not elect to 
retrofit their tank cars. However, in response to the occurrence of several spectacular 
buckling incidents involving empty tank cars, in 1985 the AAR issued a requirement that 
tank cars not presently complying with the new loading standard must be retrofitted to 
meet this standard by 1989.) 

To meet the 1974 end-load requirements for newly manufactured tank cars, GATX 
modified its design by incorporating the reinforcement bar retrofit design such that it 
could withstand the new end-load requirements. Under this revised design, RAIX 7033 
was manufactured by GATX in January 1976 as a DOT Specification 111A100W4 tank car 
specifically for the transportation of ethylene oxide. This design also included the 
attachment of a jacket anti-shift bracket welded directly to the tank shell. The anti-shift 
attachment used by GATX violated a November 6, 1971, Federal and 1969 AAR 
requirement specifying that reinforcing pads must be used between external brackets and 
shells if the attachment weld exceeds 6 linear inches of 1/4-inch weld fitted, that 
reinforcing pads must not be less than 1/4-inch, and that the ultimate shear strength of 
the bracket-to-reinforcing pad weld must not exceed 85 percent of the ultimate shear 
strength of the reinforcing pad-to-tank weld. (GATX reported that from 1971 through 
1981, more than 9,810 tank cars were equipped with anti-shift bars welded directly to the 
bottom of the tank shell under AAR-approved certificates for construction.) GATX noted 
that during this period the company's construction drawings were not updated to reflect 
the November 6, 1971, change in the DOT tank car safety standards. 

Because of Federal requirements under HM-175 for retrofitting certain tank ears 
with insulation and puncture protection for the ends of tanks, modification of this tank 
car was required. North American Car Company (NATX), an AAR-approved tank car 
fabricator, submitted an application to the AAR on September 29, 1981, to make the 
Federally -mandated modification for adding head protection and insulation. On 
December 14, 1981, the AAR Tank Car Committee approved NATX's requested 
modification as meeting both AAR and DOT requirements. 

Modification of RAIX 7033 in accordance with the AAR-approved drawing was 
completed on December 3, 1981. This AAR-approved tank car repair facility did not 
recognize that the anti-shift bracket installation did not comply with the existing Federal 
standards for protecting attachments. A representative of the repair shop stated that its 
responsibility is to ensure that a car meets all AAR requirements and regulations, but it 
does not question the design of the car. If there is a problem, the repair facility will 
notify the car owner and obtain approval to fix it. 

Records concerning the history of this tank car show that on April 25, 1983, 
stiffener bars were welded to the steel jacket of RAIX 7033 on each side of the anti-shift 
bracket. While it was not possible to determine precisely why this work was performed, 
the modification strengthened the steel jacket in the area of the anti-shift bracket. 
Apparently, stabilizing the movement of the jacket in relation to the tank had been 
difficult, and this action had damaged the jacket in the area of the anti-shift bracket. 
(The idea that the anti-shift bracket was not adequate to stabilize the jacket was 
supported on January 17, 1985, by the Safety Board's documentation of damage to the 
jacket in the area of tank bolster plate.) 

On December 31, 1984, ethylene oxide was discovered to be leaking from RAIX 7033 
while it was located in a railroad yard at North Little Rock, Arkansas. The Safety Board's 
investigation of this incident concluded that the ethylene oxide had leaked from 



-31- 

RAIX 7033 as a result of two through-shell cracks near the center of the bottom of the 
tank at each extremity of the welds on the anti-shift bracket, that the cracks resulted 
from the forces transmitted to the tank through the anti-shift bracket when the jacket 
moved relative to the tank during normal operations, that the welded connection of the 
anti-shift bracket was installed in violation of Federal standards, and that neither the 
AAR nor the FRA monitor manufacturers of tank cars for compliance with DOT tank car 
design, standards, and proper construction methods. 

During the Safety Board's investigation of the North Little Rock, Arkansas, 
accident, it learned that on April 1, 1985, GATX submitted to the Tank Car Committee 
for approval an application to modify four tank cars similar to the design as RAIX 7033, 
but not including RAIX 7033, in order to remove that portion of the existing anti-shift 
bracket in excess of 2 inches below the tank and then attach a new anti-shift jacket 
bracket either to the existing tank stiff ener bars on the bottom of the tank or, for those 
tanks not equipped with tank stiffener bars, to airbrake cylinder supports attached to the 
tank by the use of a reinforcing pad. Through this application, GATX sought to obtain a 
"precedent" for modifying similar noncomplying tank cars. In securing a "precedent" 
approval, GATX would then have been allowed to modify all other similarity noncomplying 
tank cars by filling an Exhibit R-1 with the AAR and: 

o without further review and approval by the Tank Car Committee 
since it was a previously approved procedure; 

o without complete removal of the noncomplying anti-shift anchor in 
accord with the procedure; 

o without having to notify the FRA of the modifications to the tank 
cars; and 

o by using repair methods approved in AAR's 1985 appendix R which 
had not yet been approved by the FRA. (This would have allowed 
GATX to X ray and postweld heat treat only those weld repairs 
3/16 inch in depth or 6 inches in length.) 

The AAR Tank Car Committee declined to approve the GATX application as 
submitted and requested GATX amend its application by including x ray and stress relief 
for welded repairs of tank cars transporting products under pressure. On April 9, 1985, 
GATX submitted the requested changes and on April 12, 1985, by telephonic balloting of 
Tank Car Committee Members, the application was approved. However, on 
April 15, 1985, the chairman of the Tank Car Committee in casting a negative note 
requested additional clarification of the GATX application; his position was that if either 
the 3 /1 6 -inch depth or the 6 -inch length of crack were exceeded, then postweld heat 
treatment and x ray would be required on all weld repairs. On April 19, 1985, GATX again 
revised its application incorporating the changes requested by the chairman of the Tank 
Car Committee. On April 22, 1985, the GATX application was again approved by the 
committee as being, in their opinion, in compliance with AAR and Federal requirements. 
On May 6, 1985, GATX voluntarily submitted a self-generated revision to its application 
to modify the size of the hole required in the tank car jacket for performing the 
modifications previously approved by the AAR. 

On May 17, 1985, the Safety Board made two recommendations to the FRA because 
of additional information gained during its continuing investigation of the 
December 31, 1984, incident related to RAIX 7033, the large number of tank cars 



-32- 

equipped with anti-shift brackets similar to RAIX 7033, and the fact that FRA had taken 
no action concerning the modifications being proposed by GATX. These two 
recommendation were: 

R-85-59 

Require inspection of all jacketed cars in hazardous materials service 
that have anti-shift brackets protruding outside the tank jackets for 
indications of jacket shifting or product seepage in the anti-shift bracket 
area, and remove from service all cars that exhibit symptoms of such 
distress until approved repairs are made. 

R-85-60 

Evaluate for adequacy and timeliness, directing changes as necessary, 
the General American Transportation Corporation's proposed inspection 
and repair program for bringing tank cars on which anti-shift bracket are 
welded directly to the tank shell into regulatory compliance, and monitor 
the completion of the program. 

In response to these recommendations, on June 12, 1985, the DOT issued a notice 
requiring that the DOT specification stenciling be removed from all GATX tank cars that 
have the anti-shift anchor welded directly to the tank shell. It also directed that the cars 
be removed from hazardous materials service and not be returned to hazardous materials 
service until action had been taken to bring the cars into compliance with Federal 
regulations. Concurrent with its notice, the DOT formally advised each car owner and 
lessee that they had 10 days to return affected tank cars to their destination in empty 
condition for making repairs. Also, the DOT requested to be advised about the retrofit 
schedule and field repairs. 

In response to the DOT notice, car owners and lessees began advising the DOT that 
to comply with its order they would experience extreme hardships because a large 
percentage of tank cars in their fleets would be affected by the order. The DOT received 
requests for exemption to the order as early as June 17, 1985. Included with some of the 
petitions for exemption were GATX's April 9, 1985, application for repairs that had been 
approved by the AAR. 

In response to the requests for exemption, between June 19, 1985, and July 8, 1985, 
RSPA granted exemptions affecting more than 800 tank cars. This allowed tank cars 
other than those used for transporting flammable gases to continue transporting hazardous 
materials through September 15, 1985, provided they were marked with the exemption 
number and that they were inspected to determine that there was no evidence of leakage 
in the area of the anti-shift anchor or shifting of the jacket. In granting an exemption to 
the Union Oil Company, RSPA noted that three LPG tank cars were included that already 
had been modified in accordance with the April 9, 1985, GATX modification approved by 
the AAR. The FRA, in its July 1, 1985, memorandum to RSPA, recommended including 
the three LPG cars under the exemption even though the FRA recognized that the 
modification did not comply with DOT requirements. The FRA noted that the 
noncompliance was because the anti-shift anchor had not been fully removed. The FRA 
favored including these cars in the exemption because it believed the modifications had 
reduced substantially the likelihood of tank failure as a result of the tank being torn by 
the anchor. 



-33- 

Late in June and early in July 1985, the FRA began receiving information it had 
requested from tank car owners and lessees concerning the retrofit schedule field repairs. 
At this time, FRA determined that 400 tank cars were being retrofitted by just cutting 
off a portion of the noncomplying anchor and leaving a stub on the tank. The FRA 
informed the AAR and GATX that these 400 tank cars would have to be removed from 
service and tested for cracks in the area of the anti-shift anchor stub. It further informed 
them that the April 9, 1985, AAR-approved modification did not comply with DOT's 
interpretation of its requirements and that it did not recognize as acceptable the use of 
defect-size criteria other than that incorporated in appendix R of the 1982 Edition of 
AAR's Manual on Tank Cars for Specification. 

On July 31, 1985, in response to the FRA concerns, GATX submitted to the AAR 
Tank Car Committee a fourth revision to its application for modifying the tank cars. This 
revision included a proposal to use a surface grinding method for repairing partial-depth 
cracks by grinding up to 1/1 6 -inch below the existing shell thickness without restoring the 
removed metal. 

On August 5, 1985, the Tank Car Committee met separately with the FRA and 
GATX to discuss this modification of tanks with the noncomplying anti-shift brackets. At 
his meeting, GATX advised the Tank Car Committee that it already had used the surface 
grinding method on 4,350 tank cars and that its removal of 1/16-inch shell thickness below 
that required by specifications without restoration had not comprised the safety of the 
tank cars. At this time, the Tank Car Committee advised GATX to resubmit its latest 
proposal, which included the repair by surface grinding, but to amend it by providing 
documentation and justification for use of this method. 

During its meeting with the FRA, the Tank Car Committee discussed a number of 
issues, including GATX grinding-only repair method, the AAR tank car repair 
specification pertaining to actions to be taken after removal of fractures, minimum tank 
car shell thickness, concerns that other tank cars approved by the AAR also may not 
comply with DOT regulations, the sampling of Tank Car Committee documents, 
implementation by the AAR of routine tank car builder site inspections, and improving 
communications between the AAR and the FRA. 

On August 6, 1985, GATX revised its latest proposal as directed by the Tank Car 
Committee and resubmitted it to the AAR for approval. On August 23, 1985, the Tank 
Car Committee did not approve the GATX application. Rather, the chairman of the Tank 
Car Committee requested clarification of certain aspects of the proposal which GATX 
provided. 

In an August 12, 1985, letter to the FRA's Associate Administrator for Safety, the 
AAR said of the AAR/FRA special meeting, "In principle there was no reason to 
disapprove the grinding-only method of repair for cracks 1/16 inch or less in depth and 
6 inches or less in length." In addition, the AAR stated, ". . . [the] minimum tank car 
shell thicknesses specified in Part 179 of 49 C.F.R. apply only to new tank cars," and that 
the "combination of the specification for new cars and that for repair relies on the 
stipulation of sufficient margins of surplus thickness in the new car specification to allow 
for normal repair and deterioration over the life of tank cars." The AAR letter further 
stated, "This method, concentrating on conservative standards for new tank cars to ensure 
safety over the entire life cycle has proven to be extremely successful in practice — as 
witnessed by the highly satisfactory performance record," and ". . . despite the GATX 
incident, the Committee is performing its function ably and with great success in ensuring 
that rail remains the safest mode for transport of hazardous materials. No 



-34- 



overall shortcomings in procedures or expertise are evident." Concerning improved 
relations with the FRA, the AAR letter stated, "The Committee fully endorsed an 
expanded scope of two way communications between the AAR Tank Car Committee and 
the DOT representatives" and ". . . [it] hopes that the communicative relationship can be 
formulated to become increasingly less 'reactive' and more constructively 'anticipative.' " 
The AAR suggested the following for FRA's consideration: 

At the planning level set an AAR/DOT rail hazardous material 
transportation overview group to periodically look "down stream" to 
anticipate future regulation problems and/or safety improvement needs. 
(The idea is to structure the communications system to stay ahead of 
continuous "band-aid" type responses.) 

At the day-to-day working level, establish a procedure whereby DOT 
would be provided with an excerpt summary of the agenda of regular 
AAR Tank Car Committee meetings and upon notification from DOT of 
interest, schedule a liaison briefir^ of respective representatives. 

With the assurance of strict confidentiality for proprietary information, 
add DOT personnel to the mailing list of letter ballots including 
approvals of applications of tank car builders so that DOT objections 
and/or comments could be registered as part of regular approval process. 

Schedule AAR/FRA staff briefings and technical exchanges to explore 
current concerns and/or recommendations of the concerned parties. 

On August 12, 1985, the FRA advised the Safety Board that it was monitoring the 
retrofit programs at approximately 50 AAR-certified shops to ensure that repairs being 
performed were in compliance with the DOT and AAR requirements. In its September 4, 
1985, report on the December 31, 1984, incident at North Little Rock, Arkansas, the 
Safety Board stated: 

While its prompt action to remove these tank cars from service is 
commendable, the FRA has yet to address the adequacy of the method of 
repair for these tank cars as proposed by GATX and approved by the 
AAR, and it is not monitoring the adequacy of field repairs made of 
these tank cars. The State of Louisiana furnished information to the 
Safety Board based on its inspection of field modifications being made to 
replace noncomplying anti-shift anchor attachments. The inspections 
indicate that the procedure being used for retrofitting these tank cars 
may destroy the integrity of the tank shell. For example, heat and /or 
mechanical damage may occur to the tank shell during removal of the 
existing anchor with a cutting torch or hammer. Also, the tank shell 
thickness may be reduced to less than that required by the DOT tank car 
specification as a result of grinding out surface cracks. Because more 
than 280 tank cars per week are being inspected, retrofitted, and 
returned to service using the AAR-approved method, the Safety Board 
urges the FRA to institute, without further delay, the action earlier 
called for in Safety Recommendation R-85-60. 

On August 30, 1985, the Tank Car Committee approved GATX's application 
including the use of surface grinding to remove the partial-depth cracks; however, it 
conditioned the approval by stating that it could not be used as a "precedent" in support of 



-35- 

future applications. In approving this latest application, the Tank Car Committee stated 
"that the repaired area was neither in or adjacent to any high stress area, residual stresses 
due to welding were avoided, and the stress concentration due to blended grinding was 
low." In response to the AAR action, GATX pointed out that because the AAR approval 
was not for precedent use, GATX now had authority to modify only the four cars listed in 
the application, and it was precluded from the use of this application in making 
modifications to other cars with similar deficiencies. 

At its annual meeting on October 17, 1985, the Tank Car Committee discussed the 
problem raised by GATX and it was agreed to remove the "precedent" restriction for the 
application to allow all tanks with similar deficiencies to be repaired under this 
application; however, it stated that any future use of the surface grinding method would 
not be allowed unless approved by the Tank Car Committee on separate applications. 

A DOT task force reviewed, in part as a result of deficiencies identified with 
RAIX 7033, the FRA programs related to the safety of tank cars. In its October 1985 
"Report of the Safety Review Task Force on Federal Railroad Administration Safety 
Programs," DOT noted that the task force met with the FRA to discuss various 
alternatives for achieving greater FRA involvement in the design and construction of new 
tank cars and for developing comprehensive inspection procedures for existing tank cars. 
The report noted that neither the FRA nor the AAR had a provision for monitoring 
construction of new tank cars to ensure that they conform to the approved design and that 
as a result, FRA will or has, initiated closer liaison with the AAR Tank Car Committee; 
procedures assuring improved oversight and inspection of rail tank car construction; and 
procedures for spot checking existing rail cars. The task force recommended: 

That FRA, in cooperation with RSPA, establish a closer liaison with the 
AAR Tank Car Committee during the rail tank car approval and design 
process; develop procedures to assure improved oversight of rail tank car 
construction and study the feasibility of adopting construction inspection 
requirements called for in DOT's issued NPRM HM-183 and HM-183A, 
Requirements for Cargo Tanks Used for Highway Transportation of 
Hazardous Materials, and establish procedures for spot checking existing 
rail tank cars to assure to proper construction. 

On November 22, 1985, the AAR petitioned the DOT to adopt appendix R as 
contained in the 1985 Edition of AAR's Specifications for Tank Cars M1002. On June 3, 
1986, the DOT published a rulemaking notice (HM-166U) stating its intention to adopt 
AAR's 1985 appendix R. With minor changes (not related to M1002), this rulemaking was 
published as a final rule on April 19, 1987. 

An August 27, 1986, letter from the FRA chief counsel to the AAR noted that 
recent tank car issues, notably GATX anti-shift anchor matter, have risen involving the 
role of the Tank Car Committee, the application of the AAR specifications for tank cars, 
and the DOT hazardous materials regulations. Specifically, the letter stated. 

The FRA could not accede to the AAR's conclusion stated in your 
[AAR's] letter of August 12, 1985, ... that the minimum shell 
thicknesses as specified in Part 179 apply only to new tank 
cars, . . . [ that] any deviation from the specifications lacking such 
approval by DOT violates the hazardous materials 
regulations, . . . [ that] one cannot seriously suggest that a safety 
feature required in Part 179 could be modified or eliminated with 



-36- 



impunity once a certificate of construction has been executed. Neither 
safety nor logic would countenance such a view. The hazardous 
materials regulations do not. 

Because of the implications about minimum shell thickness raised by the surface 
grinding method proposed by GATX and because of differences between the AAR and the 
FRA over interpretations of the DOT regulations concerning minimum shell thicknesses, 
both the AAR and the DOT implemented research programs to determine the effects of 
the grinding of fractures and to investigate the effect of reducing the minimum tank 
thicknesses on the effective service life of a tank car. Additionally, the FRA has stated 
that it will issue rulemaking proposals in late 1987 concerning minimum shell thickness 
and concerning nondestructive testing. During the April 9, 1987, meeting with the Safety 
Board, the AAR representative stated: 

. . . that the DOT regulations specify minimum shell thicknesses. The 
DOT specifies a 7/16-inch shell thickness as the minimum allowable for 
RAIX 7033. Until recently, there has been no indications that shell 
thickness was a regulatory or enforcement issue. The AAR Tank Car 
Committee had not previously considered the surface grinding technique 
as an option for repairing tank cars. The after-the-fact interpretation 
questions currently on the table between the AAR and the FRA are in 
the process of being resolved. As always. Tank Car Committee 
procedures will be altered to agree with the latest decisions. 

Also at the April 9, 1987, meeting, the FRA representative stated that the shell 
thicknesses prescribed by the DOT regulations was the minimum allowable and that the 
DOT regulations do not provide for reducing the stated thicknesses. 

ANALYSIS 
Emergency Response 

Initial Response Actions . — Immediately following a railroad accident, the conductor 
is responsible for providing emergency response personnel information about the train and 
its contents. When a derailment occurs involving crewmembers in the locomotive and a 
caboose, a crewmember from both the front and rear of the train inspect the train 
concurrently by walking toward the derailment to identify the last standing cars at each 
end of the derailment. This information and the train papers help to identify the cars 
involved in the derailment and save valuable time in identifying the location of the 
hazardous materials tank cars. 

In the accident at Miamisburg, Ohio, all the train crewmembers were located in the 
locomotive because the train used a rear-end marker rather than a caboose. 
Consequently, the crewmembers were isolated from the rear of the train by the river and 
the derailed cars on the bridge. The conductor initially searched the forward portion of 
the train for the two "Dangerous" tank cars, but he took no action to dispatch one of the 
other crewmembers to the rear of the train to determine which cars remained upright and 
on the rails. As a result, the conductor was able to give emergency response personnel 
only limited information on the number of cars derailed and the materials involved in the 
derailment. The firechief, therefore, had to send firefighters into the derailment site in 
full protective equipment to obtain the needed additional information. With this 
information and the assistance of the trainmaster, the conductor identified the 
phosphorus, sulfur, and tallow tank cars that were derailed on the bridge. 



-37- 

Additional delays were experienced in providing emergency response personnel 
information about hazardous materials transported by the train because of other 
ineffective actions by the conductor. When the firechief requested all information 
carried on the train, the conductor lost valuable time retrieving waybills and reassembling 
the waybills in proper order to identify all the cars in the derailment. Additionally, the 
conductor inadvertently left an emergency guide for handling phosphorus on the floor of 
the locomotive when he searched for the "Dangerous" tank car information. This 
emergency guide prominently displayed the shipper's 24-hour emergency telephone 
number, information on product hazards, and technical advice of handling emergencies 
involving phosphorus that could have aided emergency responders. 

In a review of recent rear-end train collisions, the Safety Board noted that in the 
event of either a front-end or rear-end collision of a cabooseless train, the consist list of 
materials carried on trains could be destroyed and the local emergency response personnel 
would be without a critical immediate reference. The Safety Board observed that a 
conspicuous consist list container at, on, or near the end-of-train device on a cabooseless 
train would help to correct this deficiency. Such a container could be no more than a 
large plastic yellow envelope secured to the end-of-train device with wire ties and 
lettered "CONSIST LIST" or "HAZARDOUS MATERIALS LIST." As a result of this 
review, on June 25, 1987, the Safety Board recommended to RSPA: 

R-87-18 

Require that on cabooseless trains involving hazardous materials a 
conspicuous weatherproof container be affixed at, on, or near the rear- 
end marker to hold a current consist list for use by emergency response 
forces. 

On July 31, 1987, RSPA responded that it does not plan to require such a container 
for hazardous materials consist lists and that in their view the possibility exists that cars 
may be added or removed from a train and that, consequently, the consist may not reflect 
accurately the location of hazardous materials cars within a train. In its 
September 10, 1987, letter to RSPA, the Safety Board responded that it considers that the 
benefits of having information about the hazardous materials in both ends of the train far 
outweigh any shortcomings. Further, the Safety Board added that RSPA has ignored 
certain factors and scenarios that should be taken into consideration that support 
implementation of this recommendation. The Safety Board urged RSPA to reconsider its 
position in regard to having a consist list at both ends of the train. 

As demonstrated in the train crewmembers' response to the Miamisburg accident, 
cabooseless trains can create problems for crewmembers in identifying the derailed cars 
because crewmembers are no longer located at both ends of the train. The railroad 
industry and the FRA must compensate for this operational change by developing 
procedures for cabooseless train operations so that emergency response personnel can be 
provided early reliable information about the train consist. Improved methods or 
procedures must be developed to assist crewmembers in gathering essential information 
and to prevent delays in identifying the cars and materials in the derailment. In addition, 
information on the contents of the train should be kept at both ends of the train to avoid 
the destruction of all train documents in a derailment or collision. The Safety Board 
encourages the railroad industry and FRA to examine the operating practices for 
cabooseless trains carrying hazardous materials and to develop procedures and practices 
capable of providing reliable, timely information to emergency response personnel about 
the presence of hazardous materials in derailments. 



-38- 

The lack of information regarding the location of the sulfur tank car and the 
conflicting technical advice provided on the use of water in handling the emergency made 
the job of the firechief more difficult. Although the conductor stated that there were 
three tank cars in the derailment, this information was not properly verified. Later the 
fire chief was advised that only two tank cars were involved in the derailment, and 
emergency response actions were disrupted to allow a proper accounting of cars and 
materials involved in the emergency. TTiis lack of verified information coupled with the 
previous inappropriate trainmaster's communications challenging the firechief 's authority 
initially lessened the overall effectiveness of the railroad personnel in working to support 
the local emergency response agencies. While these actions ultimately did not have a 
significant adverse effect on public safety, railroad personnel must work with emergency 
response agencies during emergencies that threaten the public and effectively use their 
experience and training to provide accurate, timely information needed by local response 
agencies in developing response actions to protect the public. 

The initial order of the firechief that the city should begin an evacuation was based 
on his observation of the direction and size of the smoke plume coming from the fire area 
and his concern about the possibility of toxic pollutants. The presence of toxic pollutants 
was later verified by air monitoring data and the large number of medical complaints 
during the incident. Furthermore, his initial decision to use a direct hose stream attack 
to flood the fire area was based on his review of available technical resource 
documentation and advice from available on-scene technical expertise. These initial 
actions provided time to assess the situation and safely complete the evacuation, to 
establish emergency resource support capabilities, and to coordinate necessary assistance 
and technical support. 

Longer-Term Actions . — The response actions, which were selected during the next 
several days by the city from the many recommended actions by various participating 
agencies and organizations, may have prolonged the duration of the emergency and 
resulted in a larger evacuation area. However, the selected response actions were 
predicated on the limitations of available firefighting equipment, on concerns for the 
firefighters safety, on the weather conditions, and on achieving maximum public safety as 
opposed to concerns about the operational inconvenience of the railroad and others. 
Miamisburg officials recognized that because of weather conditions and equipment 
limitations, many of the ideal options for handling the emergency were not possible. 
While early actions to accelerate the rate at which the phosphorus was being burned and 
applying water spary to the plume of smoke could have significantly reduced the area 
threatened by the toxic effluents, this option was not possible early in the emergency or 
until the fire was under control. 

The Miamisburg officials took early command of the emergency and implemented 
effective management procedures for obtaining and using all available technical 
assistance. The overall coordination among the many responding agencies was effectively 
managed during this 5-day emergency. Communications among the many area response 
agencies were well managed, and the high level of preparedness was reflected by the 
actions taken during this emergency. The high level of preparedness greatly assisted local 
response agencies in effectively recognizing and dealing with inconsistent information 
that was provided following the derailment. 

The problems which resulted because sulfur was involved raised additional concerns 
for Miamisburg officials primarily because of sulfur mixing with phosphorus. Molten 
sulfur is presently not regulated as a hazardous material for rail transportation. '^ " 
Safety Board believes it should be fully regulated for the following reasons: (1) it can 



-39- 

pose thermal hazards due to its molten state when transported in tank cars; (2) it can 
produce toxic pollutants when burned; (3) it can react with other materials and thereby 
increase the hazards posed during emergencies; (4) it can intensify fires occurring during 
derailments by increasing the total amount of materials subject to burning; and (5) it is 
not required to be identified as a hazardous material in the waybills, and information 
about its presence may not be provided by railroad personnel to emergency response 
agencies following a derailment. 

The DOT needs to evaluate the events at the Miamisburg accident regarding the 
involvement of molten sulfur. This nonregulated material increased the size of the spill 
area, heightened concerns for public safety because of its potential for reacting with the 
phosphorus, and increased the amount and the types of toxic pollutants emitted. The DOT 
is urged to expedite the issuance of a final rule on Docket No. HM-198 regulating molten 
sulfur as a hazardous material to insure adequate safeguards in transportation. 

Emergency Response Guides 

In its February 26, 1981, special investigation report, 36/ the Safety Board 
concluded that the guidance and technical advice provided during an April 3, 1980, 
hazardous materials emergency response at Somerville, Massachusetts, impeded the 
efforts of local officials to control the spill and increased the adverse effects of the spill 
on the community. 

The Safety Board further found that the local officials were forced to use a "trial- 
and-error" procedure during the emergency because available emergency response guides 
and on-scene technical advice were inadequate, inconsistent, and confusing. These 
findings resulted in the Safety Board issuing a recommendation to the DOT: 

1-81-1 

Investigate the adequacy and consistency of hazardous materials 
emergency guides and other advice available to local officials for use in 
controlling hazardous materials releases furing transportation, and take 
necessary steps to assure that they provide sufficient and consistent 
guidance and advice to help local officials control hazardous materials 
spills quickly and effectively. 

In its December 4, 1981, response, the DOT advised it had formed an ad hoc group 
composed of representatives from governments, industry, and private consultants to 
review the adequacy of the information contained in the DOT Emergency Response 
Guidebook and to review the guidance provided in emergency response guidebooks 
available from the B of E and the NFPA. The DOT believed that these actions would lead 
to guidebook consistency and accuracy. In 1984, the DOT issued a new edition of its 
Emergency Response Guidebook. 

On April 26, 1982, the Safety Board advised the DOT that it had classified Safety 
Recommendation 1-81-1 as "Open-Acceptable Action" and requested that the DOT provide 
quarterly reports on the progress being made by the DOT review group. The Safety 
Board's letter also noted that the DOT response had not addressed Safety 
Recommendation 1-81-2 that called for improvements in the DOT guidance provided on 



36/ For more detailed information, read Special Investigation Report~"Phosphorus 
Trichloride Release in Boston and Maine Yard 8 During Switching Operations, Somerville, 
Massachusetts, April 3, 1980," (NTSB-HZM-81-1). 



-40- 



the use of water in handling phosphorus trichloride. Although the DOT had not 
specifically addressed this safety recommendation, the Safety Board advised that it would 
hold this safety recommendation in an "Open — Acceptable Action" status until the DOT 
issued its 1984 edition of the DOT Guide. 

On July 6, 1982, the DOT advised the Safety Board the DOT review group did not 
have a fixed schedule for meeting, but it can be convened at the urging of State and local 
government, the industry, or the Safety Board. The DOT stated that the Safety ""oard 
would be informed of each meeting as it is called and has a standing invitation to attend. 
The DOT believed that this approach would be more productive than the issuance of 
quarterly reports. The Safety Board was advised that the revision of the 1980 Guide was 
being conducted by Johns Hopkins Applied Physics Laboratory and that the B of E and the 
NFPA guides specifically were being reviewed. The DOT believed that this action would 
lead to guidebook consistency and accuracy. Concerning Safety Recommendation 1-81-2, 
the DOT advised that the review group was considering changes to the guidance provided 
for handling phosphorus trichloride and that the 1984 Guide would clarify the current 
language. On August 11, 1982, the Safety Board advised the DOT that Safety 
Recommendations 1-81-1 and 1-81-2 would be classified as "Open — Acceptable Action." In 
1984 the DOT issued its revised guidebook. Based on the Safety Board's review of the 
guidance provided for phosphorus trichloride, it classified Safety Recommendation 1-81-2 
as "Closed — Aceptable Action." 

After its review of the response information provided in guides used or available for 
the Miamisburg emergency, the Safety Board remains concerned about the adequacy and 
consistency of information provided in emergency response guides published by the DOT 
and others. Despite the useful amount of information included in the available emergency 
response guides, the specific conditions for the recommended actions were not clearly 
stated in each case. For example, the term "flooding amounts of water" used in the 
guides did not have consistent meaning for either railroad personnel or the firefighters 
resulting in confusion as to the appropriate action to be taken. The railroad emergency 
specialist, who had had a similar experience, recognized that the objective for using 
flooding quantities of water was to cover the phosphorus surface to prevent contact with 
the air and that the flooding should be accomplished in the tank car. Other personnel 
interpreted the objective as flooding the area of the fire with as much water as possible. 
Another inconsistency noted among the available guides was that some guides provided 
information on the possibility of an explosion if the phosphorus combined with the sulphur, 
while other guides provided no such warnings. Also, none of the guides noted that the 
combination of phosphorus and sulphur could result in the emission of more highly toxic 
effluents than would either material by itself. 

Emergency response guides should state objectives for recommended actions, clearly 
define terms that may cause confusion to the various users, and provide essential 
information concerning potential adverse chemical interactions. The Safety Board does 
not believe that the DOT has accomplished the improvements sought by Safety 
Recommendation 1-81-1 and that it should intensify efforts for coordinating with other 
developers of emergency response guides. Thus, the Safety Board has classified Safety 
Recommendation 1-81-1 as "Open — Unacceptable Action." 

Tank Car Performance 

The Safety Board has issued many recommendations to the FRA and others for 
improving the crashworthiness of tank cars. (See appendix C.) Since 1979, the Safety 
Board has directed much of its effort for improving tank car crashworthiness to bring 
about new designs to prevent the release of hazardous materials from tank ears. 



-41- 

Tank Car Coupler and Thermal Insulation Performance .— The phosphorus, sulfur, and 
tallow tank cars sustained severe mechanical damage during the derailment. The top- and 
bottom-shelf couplers on the phosphorus tank car absorbed the initial buff forces during 
the derailment. However, the leading head on the sulfur tank car received at least two 
slits when it detrucked and struck derailing equipment. Even though coupler separation 
occurred between the sulfur and its trailing car, the outer jacket and insulation absorbed 
much of the impact forces. Following the derailment, the sulfur tank car was also 
subjected to intense heat from the adjacent burning phosphorus tank car as evidenced by 
the extent of fire damage to the steel jacket and thermal insulation on the south end of 
the sulfur tank car. During this time, the insulation reduced immediate overheating and 
allowed the firefighters additional time to cool the tank car. 

The lead end of the tallow tank car struck the trailing end of the sulfur tank car 
following coupler disengagement during the initial run-in. Both of these ends received 
punctures directly above the sills which caused an immediate release of the products. The 
sulfur car was equipped with F couplers and the tallow car was equipped with E top- and 
bottom-shelf couplers. The couplers of these cars were not restrained during the 
derailment and were not totally effective in preventing car misalignment. Had both cars 
been equipped with shelf couplers, most likely the head damages would have been 
minimized and the total quantity of sulfur and tallow released would have been greatly 
reduced. 

During the Safety Board's investigation of the Pine Bluff, Arkansas, accident 37/ on 
June 9, 1985, it discovered that the general use of shelf couplers on all types of rail cars 
would prevent derailment damages caused by failed coupler connections and would 
probably reduce the adverse effects of all train derailments. In response to Safety Board 
Safety Recommendation R-86-43, the AAR initiated interchange rule changes to promote 
use of the bottom-shelf coupler design on all types of rail cars. In its June 16, 1987, 
letter to the AAR, the Safety Board responded that it considers these rule revisions which 
facilitate the substitution of bottom-shelf couplers for E-type couplers an acceptable 
alternative to the requirement outlined in the recommendation. 

Tank Car Attachment Performance .— The phosphorus tank car, which was equipped 
with airbrake attachments welded directly to the tank, detrucked on the bridge. This 
allowed the tank car's airbrake equipment, which was closer to the ground than any other 
tank car tank appurtenance, to impact with debris and the ground. These impact forces 
then were transferred through the airbrake support directly to the tank shell which tore 
the tank car open emd thereby release large amounts of phosphorus. The other two tank 
cars that derailed had the airbrake equipment attached to the draft sill rather than 
directly to the tank. These detrucked without either of them experiencing bottom tears 
in the tank shells. 

The major breach of the phosphorus tank car through which 75 percent of the liquid 
phosphorus was released immediately after the derailment could have been avoided had 
airbrake attachments been connected to the draft sills or attached to the tank car by a 
properly designed bottom reinforcing pad. In addition, had the airbrake support been 
designed to break away before allowing the transfer of forces that tore the tank shell, this 
bottom breach in the tank likely would not have occurred. 



37/ For more detailed information, read Railroad Accident Report— "Derailment of St. 
Louis Southwestern Railway Company (Cotton Belt) Freight Train Extra 4835 North and 
Release of Hazardous Materials Near Pine Bluff, Arkansas, June 9, 1985," 
(NTSB/RAR-86/04). 



42- 

The AAR previously recognized the hazards posed to tank cars during derailments by 
bottom fittings and attachments. The Safety Board is pleased that the AAR now has 
required that all tank cars in hazardous materials service equipped with brake support 
attachments welded directly to tank shells be retrofitted by 1992. During this 5-year 
period, tank cars transporting the higher hazard commodities are being retrofitted first. 
However, in the AAR's decision in 1977 not to include protection for bottom attachments 
in its bottom outlet protection program, the AAR missed an early opportunity to address 
this safety problem as it was aware that such attachments could rupture tanks during 
derailments just as bottom outlets. Had the AAR reviewed the circumstances of the 
previous recorded failures, perhaps it would not have discounted the need to protect these 
attachments. Additionally, the FRA had no part in this decision not to include protection 
for bottom attachments since it was not determining the adequacy of actions taken by the 
AAR or determining their affect on public safety. 

When the need for reinforcing pads was first recognized by the AAR in 1971, no 
design engineering evaluation was made to determine the adequacy of this proposed 
modification to tank cars. The initially required 1/4 inch pad thickness was determined to 
be inadequate only after fatigue failure separations began occurring during normal 
operating conditions. Even after the AAR learned that its requirements for pad designs 
were deficient, it did not inform the FRA that the the Federal standard was deficient. 
Rather, it depended on tank car manufacturers to voluntarily install thicker pads. 

Other investigations by the Safety Board and by the CTC have raised concerns about 
the effect on tank car crash worthiness due to attachment designs, materials, and quality 
control used in making welded attachments to tank cars. On April 4, 1985, a leaking 
anhydrous ammonia tank car was discovered at the Burlington Northern Railroad Balmer 
Yard in Seattle, Washington. Inspection of the tank head by the Safety Board determined 
that a brittle fracture had developed in an area adjacent to the reinforcing pad. 
Metallurgical tests determined that the fracture resulted from the quality of the fillet 
weld at the stub-sill to reinforcing pad connection and the low temperature brittle 
properties of the steel used for the pad and tank head. Following this incident, the tank 
car manufacturer identified reinforcing pad cracks in at least 28 similarly manufactured 
tank cars and replaced the reinforcing pads with a fine-grain steel which had improved 
low temperature brittle properties. Additionally, the car company equipped several 
hundreds of its cars with 9- by 13-inch removable plates on the jackets to facilitate 
periodic inspections of the welds on the reinforcing pads during the service life of the 
tank cars. All remedial action has been left to the tank car manufacturer with the FRA 
and AAR collecting data on the operating experience to determine if additional action is 
necessary. 

On January 4, 1986, a sulfuric acid tank car was discovered leaking in the Canadian 
National Yard in Cambellton, New Brunswick, Canada. The tank shell, made from steel 
displaying low temperature brittle properties, developed a brittle fracture in an area 
adjacent to the reinforcing pad resulting in the leak. Of concern was the quality of the 
fillet weld at the stub-sill to reinforing pad connection and the low temperature brittle 
properties of the steel from which the pad and tank head were made. The investigation 
conducted by CTC concluded that ASTM 515 steel, as presently permitted in its and the 
FRA regulations, is not an adequate material for the manufacture of tank cars. Further, 
the CTC revised its "Regulation for the Transportations of Dangerous Commodities by 
Rail" to require the use of ASTM 516 steel for newly built tank cars used or manufactured 
in Canada. 



-43- 

The Safety Board is concerned about the longer term implications of these findings 
to other tank car manufacturers who may be using similar procedures and materials. 
Consequently, the FRA and the AAR are urged to implement an overall assessment of the 
problems being experienced with attachments to tank cars and to determine the adequacy 
of the design, quality control standards, and practices to identify improvements necessary 
in existing design and manufacturing standards and to develop and implement necessary 
modifications for existing tank cars. 

Tank Car Safety Prc^rams 

After this review of the FRA, AAR, and the CTC processes for developing tank car 
safety standards and for identifying deficient conditions and acting to remedy those 
conditions, it is clear to the Safety Board that voluntary industry actions, rather than 
FRA actions, have had the most effect on the safety standards of tank cars. This is a 
result of delegating this responsibility to the AAR. In so doing, the FRA and the CTC 
have failed to established any substantive control over the AAR's implementation of the 
delegated authorities, have not established substantive reporting requirements concerning 
actions taken by the AAR, and have not established or implemented a comprehensive 
program for periodically monitoring the actions taken on behalf of the respective 
governments. 

Before the FRA was responsible for public safety with respect to transporting 
hazardous materials by tank car, the AAR had established procedures for developing 
design standards and for controlling the safety of tank cars. When the responsibility for 
tank car safety was delegated by the Secretary of Transportation to the FRA or during 
the 20 years after, the FRA did not objectively act to assess the adequacy of the AAR's 
implementations of a major safety regulatory program. Had it done so, the FRA would 
have learned that the AAR had knowledge of many tank car deficiencies and had not 
informed the FRA. The FRA would also have discovered that the Tank Car Committee 
provided a great opportunity for members representing chemical manufacturers and tank 
car owners to control many key decisions affecting transportation safety and provided 
little or no opportunity to specifically identify or consider public safety concerns. 

The Safety Board notes that voluntary industry efforts taken through the Tank Car 
Committee generally have been good and generally have resulted in appropriate action for 
improving tank car safety. However, through such control, chemical manufacturers and 
tank car owners also are capable of influencing decisions on matters pertaining to safety, 
such as tank car retrofits and tank designs, by giving undue consideration to the economic 
impact on tank car owners and shippers and thereby adversely impact the safety of 
railroad operations and public safety. Even though well intended, the Safety Board does 
not agree with the AAR that its industry-oriented membership on the Tank Car 
Committee can in all cases give fair representation to public safety concerns. 

The removal of full center sills from beneath tank cars and the development of stub- 
sill tank cars without appropriate consideration as to the effect of this design change on 
the railroads and public safety is a prime example of such influence. The center sill 
withstood the buff forces generated during train movements, provided a safe location for 
attaching car equipment such as airbrake reservoirs, and provided protection during 
derailments for tank discontinuities such as bottom fittings and outlets. Since removal of 
the center sill, the investigations of derailments have revealed many needed safety 
improvements in the design of stub-sill tank cars for attachment methods and for 
protection of bottom discontinuities. Because the FRA took no part in the Tank Car 



-44- 

Committee deliberations on the design of stub-sill cargo tanks and because public 
participation in these deliberations was not otherwise achieved decisions were made 
without the public safety interests being independently identified and supported. 

Had the FRA required the AAR to report any actions taken or to identify specific 
tank car failures, the FRA would have been alerted earlier about the numerous and varied 
types of attachment failures. These failures were documented by the AAR during 
investigations of derailments of stub-sill tank cars and through AAR-required applications 
and Report of Repairs, R-1. Further, the FRA should have recognized that the AAR had 
not developed and implemented a program for the periodic and thorough analysis of this 
failure data in order to identify failure trends among the classes and builders of tank cars. 
Earlier recognition of this problem should have induced the FRA to require protection of 
all bottom attachments and fittings rather than accepting the retrofit protection program 
of the AAR. Had the FRA reviewed the actions taken by the AAR concerning 
attachments, it also would have become aware that the present requirement of FRA for 
installing pads between attachments and tank shells made in 1971 in response to an AAR 
petition was not adequate. 

The FRA should have implemented an aggressive program for identifying and 
assessing the adequacy of the actions taken by the AAR when it first delegated the 
authority for tank car safety. This program could have identified the imbalance on the 
Tank Car Committee and then it could have recc^nized the potential adverse effect this 
imbalance could have on tank car designs. The FRA easily could have determined that the 
engineering expertise for the design of tank cars resided almost exclusively with the RPI 
member and some of the trade organizations. Additionally, since the individual railroads 
are responsible for the losses which occur during transportation, the FRA should have 
questioned how this arrangement could meet the railroad industry's safety needs for the 
development of tank car standards much less the needs of public safety. 

Thousands of tank cars in violation of FRA specifications were identified as a result 
of the Safety Board's investigation of the accident on December 31, 1984, at North Little 
Rock, Arkansas; yet the FRA did not take effective action to ensure that proper 
corrective actions were taken. If the FRA had been monitoring the AAR actions, it would 
have become aware more quickly of the inappropriate actions being taken by GATX and 
that these actions were being approved by the Tank Car Committee. Because the FRA 
did not monitor the AAR actions, the FRA was not aware that the AAR had approved 
GATX's initial application for retrofitting the noncomplying cars in violation of FRA tank 
car specifications. Today, the adequacy of the actions approved for retrofitting these 
tank cars remains unresolved and awaits the results of research and experience during the 
operation of the retrofitted tank cars. 

Another issue identified during this review and still requiring resolution by FRA 
action was that the regulatory agencies charged with tank car safety responsibilities both 
in the United States and in Canada have not formally established procedures for 
exchanging information on tank car performance. There are no periodic meetings to 
exchange views and concerns about safety improvements for tank cars or to improve the 
operations of the AAR under the delegated authorities of both countries. The need for 
planned, periodic exchanges of information and views about matters of common concern is 
crucial. Since both countries apply the same standards to tank car design and both 
countries have delegated responsibilities to the AAR, it would be beneficial and practical 
to coordinate efforts. 



-45- 

While the AAR has recently implemented changes in its operations to exert greater 
railroad industry influence on decisions made by the Tank Car Committee, to open many 
of its records for review by appropriate governmental agencies, and to allow government 
regulatory agencies to attend portions of its meetings, the Safety Board does not consider 
these actions adequate if the AAR is to meet public safety interests. Using both the 
findings from this Safety Board review and from the FRA audit of AAR procedures, the 
FRA now must develop regulations and establish program objectives, procedures, 
reportir^ requirements, and determine that public safety interests relative to tank car 
safety are being adequately served. Among the many actions necessary, the FRA needs to 
establish procedures detailing the manner in which the Tank Car Committee must conduct 
this delegated public business, the qualifications of persons who serve on the Tank Car 
Committee, the mix of interests represented on this committee includir^ the need for 
public-at-large members, the types and extent of records that must be maintained, the 
requirements for periodic reports to the FRA, the identification of the types of analyses 
which must be performed of tank car repair records and the frequency of performing 
these analyses, the conditions under which the retrofit of existing cars must be 
undertaken, and the provisions for FRA representatives to monitor any and all activities 
associated with actions taken by the Tank Car Committee. The FRA should coordinate its 
actions with the CTC to take advantage of its experience and concerns and to promote 
the development of a single program capable of meeting the safety needs of the United 
States and Canada. 

As clearly pointed out by the Canadian Royal Commissioner following the CTC 
MacMillan Yard Inquiry (see appendix E), public participation in the Tank Car Committee 
deliberations affecting public safety is needed. The Safety Board concurs. The FRA 
should insure that the public safety needs are identified and supported in all of the FRA 
delegations to the AAR. Such an objective would insure that both the safety interest of 
the rail industry and the public are met. 



CONCLUSIONS 



Findings 



1. The lack of early information about the products and numbers of tank cars 
involved in the derailment, while not seriously affecting the initial emergency 
actions, made it more difficult to coordinate the response activities. 

2. Cabooseless train operations require additional procedures to compensate for 
this different method of operation in order to provide emergency response 
personnel timely and accurate information regarding derailed cars. 

3. The emergency response guides used during the accident caused some 
confusion because the objectives of the recommended actions were not clearly 
stated and some terms were capable of multiple interpretations. 

4. Toxic combustion effluents which threatened public safety generated by the 
burning phosphorus and sulfur were not recognized by all available emergency 
response guides. 

5. While the molten liquid form of the products involved in this derailment served 
to facilitate their loading and unloading, its liquid form contributed to the spill 
size and amount of product released. 



-46- 

6. When transported by rail, molten sulfur presents unreasonable hazards to 
public safety and should be fully regulated as a hazardous material. 

7. Local emergency response agencies effectively managed the response to this 
emergency and minimized threats to public safety. 

8. The bottom rupture and major release of phosphorus occurred as a result of 
forces imposed on the tank ear's unprotected brake support attachment and 
could have been prevented had the brake equipment been protected against 
derailment damage. 

9. The derailed sulfur and tallow tank cars without their brake support 
attachments directly attached to the tank car tanks did not have their tank 
shells torn by attachment failures. 

10. Industry was aware of the safety problem presented by the brake support 
equipment being welded directly to the tank car tank, yet action to correct 
this deficiency was not taken until after the accident at Miamisburg. 

11. Before the Miamisburg accident, the AAR Tank Car Committee failed to 
identify attachments to tank shells on stub-sill tank cars as a significant 
failure mechanism. 

12. The performance of the bottom attachment on the phosphorus tank car in this 
accident convinced the AAR Tank Car Committee that protective measures 
commensurate with the risk posed by hazardous materials transported must 
now be provided for existing unprotected tank cars. 

13. The shelf couplers installed on tank cars involved in the derailment minimized 
the extent of damages to tank heads and maintained the relative positions of 
cars in the train during the derailment. 

14. A shelf and nonshelf coupler connection does not provide adequate protection 
to prevent coupler override and tank head punctures. 

15. Steel jacketing on tank cars reduced derailment damages and reduced flame 
impingement on the car tank shells. 

16. The AAR Tank Car Committee provides the primary control over tank car 
safety both in the United States and in Canada because the regulatory 
agencies of both countries have delegated their authorities to the AAR. 

17. The FRA has not established sufficient direction or controls over the AAR's 
implementation of the authority it delegated for tank car safety to assure that 
public safety concerns are appropriately balanced against industry economic 
interests. 

18. The absence of effective FRA action for determining the adequacy of the 
AAR's implementation of the delegated responsibilities has resulted in an 
industry self-regulated system which does not provide adequate public safety 
accountability on decisions made affecting tank car designs, construction, and 
modification. 



^7- 

19. The FRA has not established appropriate reporting requirements under the 
authorities delegated to the AAR so that the FRA would have timely 
notification of potential tank car safety problems. 

20. The FRA and the CTC do not participate in any formal periodic program for 
coordination and exchange of information on matters of common interests, 
such as, deficiencies in tank car designs and the appropriate use of the AAR in 
carrying out authorities delegated to it. 

Probable Cause 

The National Transportation Safety Board determines that the probable cause of the 
uncontrollable release of phosphorus was the failure of the unprotected bottom brake 
support attachment during the derailment resulting in the tearing of the tank shell. 
Contributing to the rupture of the tank was the Federal Railroad Administration's failure 
to require retroactively that reinforcement pads be installed between tank shells and 
welded attachments. 

RECOMMENDATIONS 

As a result of its investigation of this accident, the National Transportation Safety 
Board reiterated Safety Recommendation 1-81-1 to the Department of Transportation: 

Investigate the adequacy and consistency of hazardous materials 
emergency response guides and other advice available to local officials 
for use in controlling hazardous materials releases during transportation, 
and take necessary steps to assure that they provide sufficient and 
consistent guidance and advice to help local officials control hazardous 
materials spills quickly and effectively. 

In addition, the Safety Board issued the following recommendations to: 

—to the Federal Railroad Administration: 

Establish a procedure for evaluating throughout the life of the tank cars, 
the performance of all General American Transportation Corporation 
tank cars modified to remove the anti-shift bracket welded directly to 
the track to facilitate the early detection of any failures that may be 
associated with the tank shell thickness having been reduced by the 
modification process. (Class II, Priority Action) (R-87-46) 

Define explicity those authorities concerning tank car safety delegated 
to the Association of American Railroads and establish procedures 
governing the implementation of these delegated authorites. (Class II, 
Priority Action) (R-87-47) 

Require the Association of American Railroads to report on all actions 
taken under the authorities delegated for tank car safety. (Class II, 
Priority Action) (R-87-48) 



-48- 



Develop and implement a program for effectively reviewing and 
evaluating all actions taken by the Association of American Railroads, 
tank car repair facilities, and tank car manufacturers under the 
authorities delegated to them to determine that all actions comply with 
Federal requirements for tank car design, construction, modification, 
operation, and repair. (Class II, Priority Action) (R-87-49) 

Evaluate annually the Association of American Railroads tank car 
specifications to determine that the instructions and guidance provided 
on tank car design and construction are consistent with Federal 
requirements. (Class II, Priority Action) (R-87-50) 

Coordinate a formal arrangement with the Canadian Transport 
Commission for routinely exchanging information on the performance of 
tank cars, for meeting to discuss common safety concerns related to the 
design, manufacture, retrofit, and use of tank cars, and for establishing 
controls for and the oversight of the delegated authorities for tank car 
safety. (Class II, Priority Action) (R-87-51) 

-to the Association of American Railroads: 

Determine through analysis of its "Reports of Repairs" records the 
causes of tank car attachment failures. (Class II, Priority Action) 
(R-87-52) 

Revise present attachment standards for new tank cars and require 
appropriate modification of existir^ tank cars based on deficiencies 
identified in its analysis of the causes of tank car attachment failures. 
(Class II, Priority Action) (R-87-53) 

Establish a quality control program that includes on-site inspection to 
determine that tank car manufacture, repairs, modifications, and 
alterations are performed in compliance with the tank car specifications 
approved in applications. (Class II, Priority Action) (R-87-54) 

-to CSX Transportation: 

Establish crewmember procedures for providing timely, accurate 
information to on-scene emergency responders about the types of 
hazardous materials being transported in tank cars involved in 
derailments where "end-of-train" devices are used. (Class II, Priority 
Action) (R-87-55) 

Reemphasize to all operating personnel the importance of directing their 
initial activities following a derailment to the cooperative support of 
local emergency response agencies. (Class II, Priority Action) (R-87-56) 



^9- 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

/s/ JIM BURNETT 





Chairman 


/s/ 


JOHN K. LAUBER 




Member 


/s/ 


JOSEPH T. NALL 




Member 


/s/ 


JAMES L. KOLSTAD 



Member 
PATRICIA A. GOLDMAN, Vice Chairman, did not participate. 

September 29, 1987 



-51- 

APPENDIXES 

APPENDIX A 

INVESTIGATION 



Investigation 

The National Transportation Safety Board was notified of this accident at 6:30 p.m. 
on July 8, 1986, and immediately dispatched an investigator from the Chicago Field 
Office. An invest^ator-in-charge and other members of the investigative team were 
subsequently dispatched to the scene from Washington. Individual investigative groups 
were established for operations, track, tank car performance, hazardous materials, and 
emergency response. 

Public Hearing 

The Safety Board conducted a deposition proceeding as part of its investigation of 
this accident on December 17, 1986, at Miamisburg, Ohio. Parties to this proceeding 
included the CSX Transportation, City of Miamisburg, Ohio; Albright and Wilson, Inc., 
Association American Railroads, Union Tank Car Corporation, and the Federal Railroad 
Administration. 



-52- 
APPENDES B 




National 
Transportation 
Safety Board 

Washington. D.C. 20594 



RAILROAD ACCIDENT/INCIDENT SUMMARY 



File Number: DCA 86 HZ 003 

Location: Miamisburg, Ohio 

Date and Time: July 8, 1986, 4:25 p.m., e.d.t. 

Railroad: CSX Transportation 

Type of Train: Freight 

PersOTis on Board: Four crew members 

Injuries: None 

Damage: $3,540,000 

Type of Occurence: Freight train derailment 

Phase of Operation: En route on main track 

About 4:25 e.d.t., July 8, 1986, southbound CSX Transportation (formerly Baltimore 
Ohio Railroad) freight train Extra 7614 South derailed 15 of the 44 cars in the train. The 
train was travelling about 45 mph at the time of the derailment. The derailed cars were 
the 24th through the 38th head cars of the train. The train was en route from North 
Dayton, Ohio, to Cincinnati, Ohio, with 1 locomotive unit and 44 cars. The train did not 
have a caboose. \! 

The derailment occurred at the site of a two-span through plate girder bridge about 
163 feet in length. The derailed train was the second train to proceed over the track, 
after a track surfacing gang worked on the track north and south of the bridge. 

The track at the accident location was a tangent single main track, proceeding in a 
southerly direction on a descending gradient of about 0.20 percent to the two-span 
through plate girder bridge spanning Bear Creek. Past the bridge, the gradient continued 
descending in a southerly direction at about 0.06 percent. A sidetrack extended parallel 
to the main track for about 3/4 mile on either side of the bridge on the west side of the 
main track. The main track was constructed of 132 pound RE section continuous welded 
rail (CWR), atop 9-inch by 7-inch by 8-foot by 6-inch-treated oak wood crossties, laid in 
crushed granite ballast which extended about 18 inches beneath the crossties an(^ 12 
inches or more past the ends of the crossties. "Hie width of the ballast shoulder section 
decreased near the north end of the bridge. The spiking pattern consisted of two rail 
holding spikes per tieplate, and the rail anchoring pattern was box-anchoring on each 
crosstie in the accident vicinity. About 50 percent of the rail anchors were not against 
the tie faces in the general area of the derailment. 

The bridge consisted of a two-span through plate girder bridge structure of open- 
hearth structural steel. The double track bridge rested atop reinforced concrete 
backwalls and a center reinforced conrete pier. The spans were 81 feet 6 inches in length. 



1/ For more detailed information, read Hazardous Materials Accident 
Report — "Hazardous Materials Release Following the Derailment of Baltimore and Ohio 
Railroad Company Train No. SLFR, Miamisburg, Ohio, July 8, 1986," (NTSB/HZM-87/01). 



53 APPENDIX B 

Maximum allowable timetable track speed at the accident site was 50 mph, with a 
maximum allowable timetable track speed of 45 mph beginning 0.20 mile south of the 
bridge. The bridge was located at milepost 49.7. According to the FRA Track Safety 
Standards, the classification of the track was within the parameters of Class 4 track. 
Except for the damaged bridge and track structure, the original condition of which could 
not be documented, the track met or exceeded the requirements of the FRA's Minimum 
Track Safety Standards. 

A programmed cyclic track surfacing gang had been raising the track in the vicinty 
of the bridge on the day of the accident. The track surfacing gang consisted of a 
combination tamper/liner, a ballast regulator, and a backup spot tamper. Manpower 
consisted of eight men with the track surfacing gang consisting of the machine operators, 
track laborers, and one foreman in-charge. The track surfacing was being performed 
out-of-face with a reported maximum raise of 3 inches in one pass. Out-of-face 
surfacing was performed north of milepost 49.7 and south of the bridge and was completed 
at 2:01 p.m. on July 8, 1986. 

The U.S. Weather Bureau's recorded ambient temperatures for the general area on 
July 8, 1986, is as follows: 



Time 


Temper ture 


7:00 a.m. 


72° F 


8:00 a.m. 


74° F 


9:00 a.m. 


79°F 


10:00 a.m. 


83° F 


11:00 a.m. 


86° F 


12:00 noon 


88° F 


1:00 p.m. 


88° F 


2:00 p.m. 


88° F 


3 00 D.m. 


90° F 


4:00 p.m. 


90° F 


5:00 p.m. 


90° F 



CSX Engineering Department Procedure Bulletin R-39 provides that when the 
ambient temperature is expected to exceed 85° F and out-of-face surfacing operations 
have been performed at temperatures below 85° F, the imposition of a temporary speed 
restriction of 10 mph on the track being surfaced is required during the passing of 12 
freight trains subsequent to the surfacing operation. The bulletin also requires the same 

10 mph speed restriction to be imposed on the track not dressed or having a substandard 
ballast section. The track surfacing operations on the track in question began about 

11 a.m. and continued until about 2 p.m.; no slow order was placed on the track after 
surfacing operations on July 8, 1986. 

Observations made subsequent to the accident indicated that the track structure 
immediately north of the bridge shifted laterally. Inspection of the rails and the rail 
anchors in the section of track immediately north of the bridge did not indicate any 
sudden or recent longitudinal displacement of the anchors relative to the rail. The 
maximum lateral displacement of the track structure was measured about 5 inches to the 
west at a point about 35 feet to the north of the north backwall of the bridge. 



APPENDIX B -54- 

Observations of the bridge structure indicated damage from impact with derailed 
freight cars as well as substantial thermal damage from a fire subsequent to the 
derailment. The north end of the bridge's north span was displaced about 28 inches to the 
east. Impact marks were noted on several freight cars which, although derailed, 
negotiated passage over the bridge and came to rest south of the bridge structure. 

Damage assessments provided by CSX indicate that bridge 49.7 was destroyed in the 
accident, as was 457 feet of main track wth additional 1,950 feet of main track damaged 
and 500 feet of sidetrack destroyed. 

The lateral shift of the track structure immediately north of bridge No. 49.7 is 
significant to the events of the derailment sequence. This lateral shift of the track 
structure measured a maximum of about 5 inches to the west at a point about 35 feet to 
the north of the north back wall of the bridge. It is improbable that this lateral shift of 
the track structure could have occurred due to the dynamics of the derailment sequence 
itself. The lateral force necessary to accomplish such a displacement typically manifests 
itself as rail turned over in the edge of the seat of the tieplates or as rail displaced 
laterally from the seat of the tieplate. Further, there were no indications, such as bent- 
over track spikes or tieplace displacement to support a theory of lateral track 
displacement resulting from the dynamics of the derailment sequence. 

The lateral shift of the track structure was also unlikely to have occurred as a result 
of thermal stresses. Although thermal damage to the bridge structure was significant, the 
rail does not possess the degree of lateral rigidity that would have been necessary to 
transmit those stresses laterally and force the entire track structure intact, 5 inches 
through the roadbed. Further, the freight cars sitting on the track after the derailment 
and through the fire would have significantly arrested lateral shift of the track structure. 
The transmission of thermal forces longitudinally through the rails was not possible in this 
particular situation since the rails were not restrained on the bridge structure itself 
during the fire. Expansion of the unrestrained rails from the fire's heat could not have 
been transmitted through the restrained rails in the ballast roadbed. 

Although the ballast shoulders surrounding the track structure north of bridge No. 
49.7 were sufficiently wide, more than half of the depth of the crossties were exposed. 
This condition seriously impaired the ability of the ballast shoulder section to resist 
lateral forces. The ballast track section had also been disturbed by the out-of-face track 
surfacing operation conducted shortly before the derailment. The maximum raise of the 
track was reported to have been 3 inches, raised in one pass. The National Transportation 
Safety Board believes that it was poor practice not to have imposed a slow order on the 
track until the track could have regained stability. 

The conditions noted at the accident site and the practice employed in the track 
surfacing operation indicate that the 5-inch lateral shifting of the track very likely 
occurred during the passage of the freight train, which in turn derailed due to the track 
shifting underneath. The dynamic forces imposed by the passing train in combination with 
the inadequate condition of the ballast section probably caused the lateral shift of the 
track structure. Whether the entire 5 inches of track shift occurred at once or some 
minor portion of the track shift was attributable to the derailment sequence or the 
thermal stresses could not be determined. See the attached brief of accident for the 
Safety Board's determination of probable cause for the derailment discussed in this 
summary report. 



-55- 



APPENDIX B 



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-56- 



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-57- 



APPENDK C 

SAFETY BOARD RECOMMENDATIONS 

FOR IMPROVEMENT OF HAZARDOUS MATERIALS 

OF TANK CAR SAFETY 

Since 1968, the Safety Board has made 57 recommendations to DOT and AAR for 
improving tank car safety. Those recommendations issued by the Safety Board which are 
applicable to tank car safety are listed below by the subject of the recommendation. 



Delegations 



Recommendation 



Status 



R-69-011 Closed— Acceptable Action 
R-78-028 Closed— Unacceptable Action 

Data Requirements 

R-79-016 Closed— Acceptable Action 
R-80-014 Closed— Acceptable Action 



Safety Analysis 

R-69-028 Closed— Acceptable Action 

R-72-020 Closed— Acceptable Alt.Action 

R-75-016 Closed— Acceptable Alt.Action 

R-78-029 Closed— Acceptable Action 

R-78-030 Closed— Acceptable Action 

R-78-033 Closed— Acceptable Action 

R-78-059 Closed— Unacceptable Action 

R-79-024 Closed— Acceptable Action 

R-80-012 Closed— Acceptable Action 

R-80-015 Closed— Unacceptable Action 

R-81-074 Closed— No Longer Applicable 

R-81-075 Closed— No Longer Applicable 



Monitoring Repairs and Retrofitting 

R-78-030 Closed— Acceptable Action 

R-78-031 Closed— Acceptable Action 

R-85-012 Open— Acceptable Action 

R-85-023 Closed— Unacceptable Action 

R-85-059 Open— Acceptable Action 

R-85-060 Open— Unacceptable Action 

R-85-099 Open— Acceptable Action 

R-85-117 Open— Acceptable Action 

R-86-043 Closed— Acceptable Alt.Action 



Tank Car Design and Construction 

Recommendation Status 

R-69-008 Closed— Acceptable Action 

R-69-029 Closed— Acceptable Action 

R-71-009 Closed— No Longer Applicable 

R-71-010 Closed— No Longer Applicable 

R-72-021 Closed— Acceptable Action 

R-72-022 Closed— Acceptable Action 

R-72-024 Closed— No Longer Aplicable 

R-74-031 Closed— Acceptable Action 

R-74-033 Closed— Acceptable Action 

R-75-016 Closed— Acceptable Alternative Action 

R-75-019 Closed— Acceptable Action 

R-78-019 Closed— Acceptable Action 

R-78-020 Closed— Acceptable Alternate Action 

R-78-021 Closed— Acceptable Action 

R-78-022 Closed— No Longer Applicable 

R-78-058 Closed— Acceptable Action 

R-79-023 Closed— Acceptable Alternate Action 

R-79-024 Closed— Acceptable Action 

R-79-028 Closed— No Longer Applicable 

R-79-065 Closed— Acceptable Alternative Action 

R-79-066 Closed— Acceptable Action 

R-79-067 Closed— Acceptable Alternative Action 

1-80-003 Closed— Acceptable Alternative Action 

R-80-010 Closed— Acceptable Action 

R-80-011 Open— Unacceptable Action 

R-80-013 Closed— Acceptable Action 

R-80-014 Closed— Acceptable Action 

R-80-016 Open— Acceptable Alternative Action 

R-85-061 Open— Acceptable Action 

R-85-063 Open— Acceptable Action 

R-85-064 Open— Acceptable Action 

R-85-105 Open— Unacceptable Action 



-58- 



APPENDIX D 

SUMMARY OF FEDERAL RAILROAD ADMINISTRATION 

DELEGATION OF AUTHORITY TO ASSOCIATION OF AMERICAN RAILROADS 

FOR TANK CAR SAFETY AND 

RELATED FRA AND AAR PROCEDURES AND OPERATIONS 

L DEPARTMENT OF TRANSPORTATION REGULATORY REQUIREMENTS 

Title 49 CFR 179 Subpart A lists the requirements and procedures for securing tank 
car approval and changes to tank car specifications. The following requirements are 
delineated. 

A. Delegation of Authority 

179.3— Delegates to the Secretary, Mechanical Division, AAR, (Secretary) 
authority to issue, based on appropriate committee action, approvals for 
designs, materials, construction, conversion, and alteration of tank car tanks 
when such is compliance with DOT specifications. 

B. Certification Requirements 

179.1— Provides general requirements for tank cars. Requires that tank cars 
must be built to the specifications of 49 CFR Part 179, that cars built to 
specifications predating those of the current 49 CFR Part 179 may continue in 
use as provided by 49 CFR 173.31, requires persons performing any function 
prescribed in 49 CFR Part 179 must do so in compliance with 
49 CFR Part 179. 

179.5— Requires the party assembling a completed tank car to provide, before 
the car is placed into service, a Certificate of Construction (Form AAR 4-2) 
to the owner, to the B of E, and the Secretary certifying that the tank, 
equipment, and car completed comply with all the requirements of the 
specification (Department's). If the tank is of Class 106A, 107 A, or llOA, then 
before it is placed in service, then the builder must also provide a Certificate 
of Inspector's Report certifying that the tank and appurtenances comply with 
all the requirements of the specifications. In addition, CFR 179 incorporates 
by reference specific AAR "approved" standards and practices in the AAR 
Tank Car Manual since 1982; 1/ however, approval is exercised by AAR based 
on current DOT and AAR requirements. The AAR requirements do not 
conflict with Federal regulations. 

C. R-1 Report of Welded Repairs, Alteration, or Conversion 

179.6— Allows repairs or alterations to be made to tank cars by following 
procedures of appendix R of AAR Specifications for Tank Cars - 1982 edition 
of the Tank Car Manual. AAR approval for specific repairs or alterations is 
generally not required if the procedures in Appendix R are followed or if the 
repairs or alterations were previously approved for other cars. Repair is 
defined to include reconstruction of a tank to its original design, and 
alteration means changes in tank or fittings that do not change the 



1/ On April 19, 1987, RSPA adopted the 1985 Edition of AAR's Specifications for Tank 
Cars, M1002. 



-59- APPENDIX D 

specification but which do change the Certificate of Construction. Thus, the 
discretion is granted to the Tank Car Committee to approve procedures and 
materials incident to repairs and alteration as long as they are in compliance 
with the applicable specification. Changes to appendix R of the Tank Car 
manual in any later edition (after 1982) have not been incorporated by 
reference in the DOT regulations, but no changes have been made which 
conflict with DOT specifications. 

D. DOT Exemptions 

179.3— Requires, when in the opinion of the Committee, such tank or 
equipment does not comply with DOT regulations and specifications then the 
Committee may recommend service trials to determine the merits of a change 
in specification. Service trials cannot be conducted unless authorized by the 
Department under the terms of "DOT Exemptions." 

E. Proposals for Changes to the DOT Specifications 

179.4— Delegates to the Secretary, AAR, the responsibility for progressing 
proposed changes or additions in the specifications for tanks. Provides for 
submission of application to use any specification change proposed but 
disallows the construction of any tank to the proposed specification until such 
specification is approved or DOT Exemption has been issued. 

n. AAR PROCEDURES 

The following AAR procedures cover the implementation of the above DOT 
requirements. 

A. Tank Car Committee 

General Committee .— Under AAR Standard S-046, Section 10.0, Approvals 
(M-1002), an item of equipment, practice, design, product, device or facility 
has been "approved" by the AAR Mechanical Division when it is found to meet 
the applicable standard, alternate standard, or recommended practice. The 
General Committee is responsible for the execution of the responsibilities for 
the Mechanical Division including the above "approvals." 

The Tank Car Committee is a standing committee of the General Committee 
and is subject to the rules and guidelines of the General Committee; 
specifically under Circular No. D.V. 2077 -Articles of Organization (Revised 
1986), the General Committee: 

designates the chairman and vice-chairman of the Tank Car 
Committee, the term of office is for 2 years; 

approves Tank Car Committee membership based on 

recommendations from "member roads" and "others" having 

responsibility for the design, construction, maintenance of car 
equipment; 



APPENDIX D -60- 



approves for the Mechanical Division, reports and 
recommendations of the Tank Car Committee docket in 
accordance with AAR Standard S-050; or 

any member of the Mechanical Division or anyone else ("-050) can 
request to have a specific matter docketed for consideration by the 
Tank Car Committee. 

The Executive Director (Assistant Vice President-Mechanical Division) or 
delegated representative is responsible for establishing a file and record of all 
Tank Car Committee transactions; setting meeting dates for the Tank Car 
Committee at least twice a year; and attendir^ the Tank Car Committee 
meetings. 

The Secretary-Mechanical Division is required to maintain a complete record 
of the transactions of the Tank Car Committee. 

B. DOT Procedural Requirements 

Under 49 CFR Part 179, DOT requires the following procedures in securing ear 
approval. 

The procedure for tank car approval requires submission in the form prescribed, 
including detailed prints, to the Secretary for consideration by Committee on Tank 
Cars (Committee) and other appropriate committees. Approval or rejection is based 
on committee action to be issued by the Secretary. Applications can be approved 
only when, in the opinion of the Committee, such tanks or equipment complies with 
DOT regulations and specifications. 

When, in the opinion of the Committee, such tanks or equipment do not comply with 
DOT regulations and specifications then the Committee may recommend service 
trials to determine the merits of a change in specifications. Service trials cannot be 
conducted unless authorized by the Department under the terms of DOT 
Exemptions. 

C. AAR Approval Process 

Under Section 1.3.6 (M-1002), the Tank Car Committee is authorized to approve the 
following: 

design and materials for fabrication, alteration, conversion or 
welded repairs; 

design and materials for all valves and fittings on tank cars; 

design, materials, and flow capacity ratings of safety devices used 
on tank cars; and 

revisions or substitutions of any valve or fittings, or the addition of 
supplemental valves or fittings to the tank or to those fittings 
covered by the certificate. 



-61- APPENDIX D 



Under Section 1.4 (M-1002), the application for approval (4-2) of designs and 
materials must be submitted to the Secretary, Mechanical Division, the B of E, and 
the Tank Car Committee, and when required by AAR specification M-lOOOl, to 
other appropriate committees for approval of brake systems and car structure. The 
RPI representative of the Committee does not receive applications and drawings. 

The office of the Secretary may process and approve applications on the behalf of 
the Tank Car Committee provided such applications are with precedent in that they 
are similar to previously -approved applications; otherwise approval requires Tank 
Car Committee ballot by majority vote and no dissenting comments from the 
chairman, the B of E, or the Mechanical Division. Comments must state if they are 
based on violations of the specifications or represent a hazardous condition. 

In securing approval for construction of tank cars, AAR has four requirements of the 
applicant. In that the car company must be an AAR certified shop, use only the 
AAR approved drawing in building the car, follow the AAR fabrication practices and 
inspections , and submit a car certification to the AAR; specifically: 

Step #1 . The car company must prove its fitness as an AAR certified 
shop. These certification procedures and detailed requirements for AAR 
approval of facilities for fabrication, assembly, alteration, conversion, 
repair and associated testing of tank car tanks are contained in appendix 
B of the AAR Specification M-1002, Specification for Tank Cars. 

Step #2 . The car company must secure approval from the AAR that the 
car design is in compliance with DOT specs. RSPA delegates to the 
Secretary, AAR authority to issue, based on appropriate committee 
action, approvals for design, materials, construction, conversion, and 
alteration of tank cars when such is in compliance with DOT 
specifications. These procedures employed for carrying out the 
delegated authority are covered in the tank Car Manual (M-1002) and the 
Mechanical Division's Articles of Organization (revised 1986). 

Step #3 . The car company must build the car according to the approved 
drawings and perform required AAR inspections. The procedures are 
listed in the Tank Car Manual. 

Step #4 . The car company must finally certify that the car complies with 
DOT requirements. The designated car company officer must certify 
that the car conforms to all applicable DOT and AAR requirements, 
including specifications, regulations. Rules of Interchange and the DOT 
Railroad Safety Appliance Standards. In addition, the car company must 
place the DOT specification mark on the tank car. The builder must 
submit a properly executed certificate of construction certifying that all 
functions performed bv the builder complies with the requirements of 49 
CFR Part 179. 

Procedures for Changes to the Regulations 

DOT Procedural Requirements .— 49 CFR 179.4 requires applicant proposing new or 
changed specification to furnish information to justify the proposal including 
information on the properties of the lading and the method of loading and unloading. 



APPENDIX D -62- 

The Tank Car Committee shall review at its earliest convenience the proposal. The 
Committee shall report its recommendations to the Department. These reports of 
recommendations may be submitted to the B of E, AAR, for its recommendation 
before action by the Department. The Department shall give due consideration to 
the expert opinion obtained in determining what, if any, action to take. 

AAR Procedures for Considering Proposals Regarding Standards and Recommended 
Practices, Specifications and Rules (Standard S-050) 

Proposals may be submitted by a railroad, car builder, component manufacturer, 
private car owner or any other person or organization to Director, Technical 
Committees, AAR Mechanical Division (Director). Director will review proposal 
and assign it to relevant technical committee. 

Relevant technical committee or subcommittee thereof will review proposal and as 
a part of its considerations may request the proponent to submit additional 
information or to appear before committee or subcommittee to explain in detail and 
to answer questions not resolved by the written material. 

One of two possible actions may be taken by committee. It may reject the proposal 
which requires notification to the proponent of the rejection along with a written 
explanation addressing matters raised by the proponent. The proponent then is able 
to resubmit its proposal with any additional information available for 
reconsideration by the committee. 

The second action available is to "progress" a proposal. In this event, the technical 
committee must publish either in the Mechanical Division Circular Letter or in the 
committee's Annual Report its intention to progress the proposal and solicit 
comments from interested parties. 

Comments to proposals must be considered by the appropriate committee before 
taking final action. The final action and an explanation of the action taken must be 
published in a Mechanical Division Circular and all commentors must be advised of 
the committee's response to comments. 

Final actions by committees then must be submitted for approval to either the 
membership of the Mechanical Division at the annual meeting or the General 
Committee, Mechanical Division, at times between annual meetings. Approval by 
majority vote of either group may direct the committee to take final action which 
must be submitted for letter ballot vote to the AAR member railroads. 

New or amended standards and recommended practices approved as above must be 
published in the Manual or Standards and Recommended Practices. New or amended 
revision of the Interchange Rules approved as above are referred to the Arbitration 
Committee for final action as to which rule, paragraph, and /or subparagraph will be 
modified and for development of the exact wording of the modified interchange 
rule. 

ffl. MONITORING 

The FRA monitors tank car safety in several ways. On a daily basis, FRA field 
inspectors monitor selected tank car facilities. In addition, FRA headquarters 
reviews accident/incident data and is now attending AAR Tank Car Committee and 
AAR Hazardous Materials Steering Committee meetings. 



-63- APPENDIX D 

AAR monitors tank car safety in several ways. Facilities are inspected for 
recertification every 5 years, more often if warranted. AAR inspectors can audit 
tank car facilities and the performance of AAR-approved tank car work at any time. 
In addition, AAR Hazardous Materials Systems inspectors perform educational 
audits of tank car safety at B of E members' plants. 

The railroads are constantly monitoring tank car safety in rail transportation and, as 
defective cars and components are identified, AAR systems are utilized to define 
car populations and to alert the railroads and effect removal of cars with 
deficiencies from service. 



-64- 

APPENDIX E 
ASSOCIATION OF AMERICAN RAILROADS RESPONSES TO SELECTED QUESTIONS 

The Association of American Railroads (AAR) provided the following in regard to a 
Safety Board request for additional information on March 20, 1987. The following 
questions along with the AAR responses have been grouped into three major areas 
covering: delegations of authority /requirements, procedures, and monitoring. 

Department of Transportation Regulatory Requirements 

A. Delegation of Authority 

1. What individual(s) at the AAR has primary responsibility for tank car safety? 

The Assistant Vice President-Mechanical Division. This position has 
responsibilities that embrace general hazardous materials transport as 
well as all aspects of tank cars. 

2. In what other areas in addition to CFR 179.3 is the authority delegated from 
DOT to the AAR? 

This question certainly can and should be answered by DOT; however, we 
can point to delegations in 173.31, 174.8 and numerous delegations in 
Part 179. A careful examination of 49 CFR will delineate the specific 
details. 

3. Under CFR 179.3, is this authority further delegated from the Secretary to 
staff, representatives, and/or standing committees in the AAR? 

The delegation of authority, in accord with 179.3 is to the Tank Car 
Committee, who may seek specific expertise from other AAR technical 
committees. 

4. With whom does the delegation of authority eventually end? What 
organizations do these individuals represent? Are the individuals authorized to 
vote in behalf of the organizations they represent? 

The delegation of authority is to the Tank Car Committee or the Bureau 
of Explosives, as indicated by the regulation. The Tank Car Committee 
members have direct technical expertise in hazardous materials 
transportation and are appointed from candidates recommended by 
individual railroads and industry associations. The qualifications of each 
representative is separately evaluated and approved by the Mechanical 
General Committee. The individuals vote according to the dictates of 
the technical expertise that they possess as related to the issues 
involved. 



-65- APPENDIX E 

5. Does 49 CFR delegate discretionary authority to the AAR? In what specific 
areas? 

According to Mr. J. M. Mason's letter of August 27, 1986, certain 
provisions of Part 179 delegate discretionary authority to the Tank Car 
Committee. 

6. In reference to Mr. Mason's letter of August 27, 1986, to Mr. A. Johnston, is 
the AAR in agreement with the points raised? Please explain. 

The AAR generally agrees with the conclusions of Mr. J. M. Mason's 
letter of August 27, 1986. The AAR does not enforce or promulgate 
requirements that are in conflict with the regulations. 

7. What criteria exists for performing evaluations of the delegated authority and 
periodically assessing whether or not the delegation should continue? 
Frequency, periodic reporting requirements, at what level? 

DOT/FRA exercises oversight consistent with their responsibility. There 
is routine interaction between AAR and FRA, including attendance of 
FRA personnel at recent Tank Car Committee and Bureau of Explosives 
Steering Committee meetings. Circulation of periodic reports of 
Mechanical Division activities. Early Warning Letters, and Maintenance 
Advisories Letters are regular practices. Also, there are numerous 
written inquiries from FRA to AAR concerning condition and status of 
rail equipment. Information exchanges and inquiries occur at both 
management and working levels. Formal communications are normally 
between the Associate Administrator for Safety and the AAR Assistant 
Vice President-Mechanical Division. 

B. Certification Requirements 

1. Under CFR 179.5 why does the B of E get a copy of the application in addition 
to the Secretary? 

The Bureau of Explosives is copied for coordination purposes. The intent 
is to apply the widest possible scope of expertise to the application 
approval process. 

2. Car owners are certified according to which edition(s) of the Tank Car 
Manual? 

Certification is to the current issue of the Specification for Tank Cars. 
It is realized that in some instances there is a time delay in DOT's 
incorporation by reference of AAR's current issue; however, past 
differences have mainly only been of an administrative nature. The AAR 
is not aware of any cases where use of current versions of standards has 
resulted in substantive safety and/or regulatory concerns. 

C. R-1 Report of Welded Repairs 

In reference to Mr. A. Johnston's letter of August 12, 1985, to Mr. J. Walsh, AAR 
maintains that "repairs and alterations to tank cars are governed by appendix R of 
AAR Specification for Tank Cars pursuant to 49 CFR 179.6 and by 173.31, not by 



APPENDIX E -66- 

the Part 179 requirements." Please explain the basis for this interpretation. Have 
other R-l's been submitted which allowed old cars to be repaired without meeting 
Part 179 requirements? If so, under what conditions? If so, number of cars 
affected? 

Rather longstanding past industry practice is not in complete accord with Mr. 
J. Mason's letter of August 27, 1986. Clarification is being sought at this 
time. We are aware of no R-l's that have been inconsistent with the 
regulations and interpretations that were in effect when the forms were 
submitted. Where mandated, retrofits have been effected in accord with the 
provisions of subsequent rules. 

D. DOT Special Permits 

1. Are these practices still in effect? When are they employed? 

Traditionally, proponents have gone directly to DOT for approval for 
deviations from the regulations. 

2. In what specific area has the Committee used this delegation? Examples. 

The Tank Car Committee has exercised the delegation only to advise 
proponents to seek exemption directly from DOT. Service trials which 
may be in conflict with the regulations are handled in the same way. 

E. AAR Proposals for Changes to DOT Specifications 

1. Under Section 2.3 (M1002) car companies must meet the "proposed revisions" 
to the specifications regardless if they are adopted or not by DOT. Why is the 
AAR seeking DOT's approval? Has DOT previously rejected an AAR proposal 
for changes to tank car specifications under Section 2.3? 

Section 2.3 of M-1002 is consistent with or exceeds the regulations. 
AAR seeks DOT approval and publications to make the regulations as 
stringent as need be for maximum safety. Certain AAR proposals have 
been rejected and subsequently approved with appropriate modifications. 

2. What AAR proposals for regulatory changes have been docketed by the Tank 
Car Committee for 1987? 

A review of the March 1987 Tank Car Committee agenda shows the 
following proposals for regulatory changes: 

Docket Subject 

T76. 16-85 Alternate Gasket Materials 

for Liquefied Flammable Gas Service 

T73.6-86 Outage Requirements 

T79.4-83 Obsolete Specifications 



-67- APPENDIX E 

T94.14-84 Yield Strength vs. Ultimate 

Strength for Shell Thickness 

T94. 16-85 Minimum Wall Thickness Requirements 

T95.7-81 Use of Steels in Tank Cars 

T95.10-82 Alloy Steel Castings 

T-75.7-86 Removal of Commodity Stencil From 

Cleaned Tank Cars 

3. What is the Subcommittee on Specifications? 

The Subcommittee on Specifications no longer exists. It was replaced 15 
years ago by the members of the Tank Car Committee, functioning as 
two subcommittees in considering the proposals that have been 
developed by subordinate working groups. Recommendations of the 
Subcommittees are further considered by the full committee at its 
meetings. 

4. Since the B of E is also part of the AAR, for what reasons would applications 
and proposals be referred to the B of E? 

See our response to V.B.I. 

5. Who in the B of E receives and reviews the above? What are those persons 
qualifications? 

The properly constituted Steering Committee of the Bureau of 
Explosives addresses all referrals. Qualifications of staff personnel are 
duly reviewed. The AAR 0-T General Committee approves appointment 
of all Steering Committee members based on technical qualifications. 
Generally, B of E personnel are qualified over a broad spectrum of 
hazardous materials concerns. 

6. What records of AAR proposals are kept and to whom are they available? 
Under what conditions? 

AAR staff supporting the Tank Car Committee and the Bureau of 
Explosives Steering Committee maintains lists of present and past 
petitions to DOT. These are public documents and are readily available. 

Procedures 

A. Tank Car Committee 

1. Who may serve on the Committee? 

All who are technically qualified and duly appointed under the bylaws 
and authority of the AAR Mechanical Division General Committee. 



APPENDIX E -68- 



2. How is the committee constituted? 

The committee is constituted in accord with the referenced bylaws. 
Currently there are 16 voting members authorized. 

3. What organization does the Chairman of the Tank Car Committee represent? 
Ethyl Corporation /CM A? 

The chairman of the Tank Car Committee serves the committee to 
facilitate its deliberations. The current chairman, who took office in 
1985 and will step down in June, 1987 is employed by Ethyl Corporation, 
which is a member of CMA. 

Provide same information for other members of the committee. 

At present there are 10 railroad and 6 non-railroad voting memberships 
authorized. 

4. What procedures must the Committee follow in carrying out the delegated 
authority? 

Committee procedures are conducted in accord with Robert Rules of 
Order. Agendas are prepared and issued prior to meetings, and minutes 
are recorded and kept. Proponents are offered the opportunity to 
present evidence at predetermined and dedicated portions of meetings. 
Tank Car Committee members who may have a semblance of conflict of 
interests on certain dockets are not permitted to be present during 
discussion and voting on these subjects. 

The Tank Car Manual (M-1002) prescribes procedures to be followed in 
considerations of applications for approval of designs and for facility 
certification. 

5. What records of the Committee must be open for public inspection? For FRA 
inspection? Other inspections and by what organizations? 

Public inspection is available on appropriate request. FRA has availed 
itself of the right to audit transactions as deemed necessary. In certain 
circumstances legal depositions have been honored. 

6. Define the term "majority" as it relates to the number of Committee votes 
necessary for approval of an action? 

Majority means a plurality of the voting members present, provided that 
a prescribed quorum exists. Letter ballots must have a majority of all 
eligible voting members. 

- Do all members have to vote for an action to receive approval? 

It is not necessary for all members to vote for an action to receive 
approval. A majority of a quorum is sufficient at meetings. 



-69- APPENDIX E 

- Is this procedure always followed? 

Yes. 

- Do specific interest groups (car manufacturers, railroads, etc.) abstain from 
votir^ on certain dockets? Which groups vs. which types of actions? Trends? 

Members abstain when there may be a potential conflict of interest or a 
direct involvement. Moreover, they absent themselves from all 
discussion and voting on such propositions. 

7. What special interest balance is required in appointing Committee members? 

At the present time the balance prescribed by the Mechanical Division 
General Committee is 10 railroad and 6 non-railroad voting members, 
with the chairman appointed (and properly approved) from among the 
railroad members. 

8. How are public safety concerns introduced, supported, and weighed in the final 
voting? 

Both railroads and the non-railroad members have a lot at stake if any 
deficiencies in safety occur. Final voting invariably reflects this fact. 
The safety performance record of hazardous materials transportation by 
rail is the bottom line and is, we believe, extraordinarily commendable. 

9. What are the other AAR committees to which applications may be submitted? 

All applications are submitted to and final disposition is made by the 
Tank Car Committee. 

Other AAR committee, such as the Hazardous Materials Systems (BOE) 
Steering Committee, the Car Construction Committee and the Wheels, 
Axles, Bearings and Lubrication Committee are called upon by the Tank 
Car Committee as needed to supply specific expertise to address issues 
associated with the safe transportation of hazardous materials by rail. 
Recommendations from these committees are considered in the decision 
process; however, actions on applications rest solely with the Tank Car 
Committee. 

- What are the qualifications of their memberships and their makeup? 

Qualifications are based on expertise in the particular technical 
discipline needed for the committee. Such qualifications are offered in 
writing for each candidate from officers of the sponsoring organization 
and are approved by the Mechanical Division General Committee, which 
is comprised of the Chief Mechanical Officers of member railroads. 

- What procedures must they follow? 

The procedures utilized are stipulated in the bylaws of the Mechanical 
Division. 



APPENDIX E -70- 

- What weight might they have in approval or rejections? 

See above. 

- What records must be maintained? What records are open to inspection and 
by what agencies or entities? 

Records are kept, maintained and are available as described in the 
response to V.A.5. 

B. Procedures for Changes to the Regulations 

Under what conditions are AAR proposals for changes to DOT Specifications on tank 
cars submitted to the DOT for review? Was the proposal dated 1-23-81 by R. Thelen 
(T-94.2-80) submitted to the DOT? If not, why not? 

AAR-adopted proposals for changes to DOT specifications for tank cars are 
always submitted in petitions to DOT. Mr. Thelen's letter of January 23, 
1981, which you have referenced, was not such a proposal. 

C. AAR Approval Process 

1. Why and how are the AAR's M-1002 standards different from the FRA 
standards? 

Any differences can be attributed to the basic philosophy that the 
federal regulations contain the requirements and the AAR ^1-1002 
standards specify the methodologies of accomplishment. There are 
certain instances where AAR specifications go beyond FRA 
requirements. This is because these AAR standards are formulated to 
provide additional safety margins and thus can exceed minimum federal 
requirements. 

2. How does the AAR see these two standards as different/or similar? Are both 
necessary? 

See reply above. 

Both are necessary in order to provide details for implementation and to 
facilitate sufficient attention before the condition specified in the 
federal requirements is reached. 

3. Does AAR grant approval of alterations and repairs based on the latest edition 
of the Tank Car Manual? 

AAR does approve alterations and repairs based on the current issue of 
M-1002. 

- In this area, were deviations from the DOT specifications allowed? 

No. 



-71- APPENDIX E 

- Were the builders/repairers aware of the difference? 

Builders/repairers should be confident that no differences on any 
consequence exists. 

4. Is the GATX anti-shift bracket an example of the above? Specifically what is 
the minimum allowable shell thickness permitted by AAR? And DOT? How 
has this difference been resolved? 

DOT regulations specify shell thickness. Until recently there were no 
indications that shell thickness was a regulatory or enforcement issue. 
The after-the-fact interpretation questions currently on the table are in 
the process of being resolved. As always Tank Car Committee 
procedures will be altered to agree with latest decisions. 

Monitoring 

Are all R-l's used to determine trends or identify critical defects in accident? How 
is this assessment made? Please cite a few examples where critical defect in tank 
car components have been identified on the basis of R-1 report reviews. Describe 
the data storage and retrieval system used? 

R-1 forms are reports of repair, alteration or conversions made to tank cars in 
accord with previously approved procedures. Patterns of repair vs. operating 
experience are often used for correlation purposes. Assessments are made 
through analytical comparisons by AAR staff members. One example was in 
the detection and isolation of non-pressure stub sill tank car buckling 
tendencies, wherein a retrofit modification was imposed. 

All tank car attributes are submitted and contained in a file of certificates of 
construction. Both manual and automated data processing systems are 
available to assist in analysis. A mechanized data base of equipment details 
(UMLER) is also regularly utilized. 

Does the AAR have a critical defect program for identifying defective tank car 
components and advisir^ the industry when a critical defect is identified? What 
procedures must be followed? 

Defective tank car components are identified and traced chiefly by the "hands 
on" experience and monitoring efforts of the railroads who are intimately 
involved in the movement of the cars. Appropriate AAR committees 
determine severities and recommended remedies to the Tank Car Committee, 
depending on the particular nature of the problem. 

Established Early Warning and Mechanical Advisory systems are used to alert 
railroads and to effect removal of cars with deficiencies from service. 

When a problem is identified in a portion of a car owner's fleet, what procedures 
does the AAR require the car owner to take in identifying the problem? When is the 
FRA involved? 

When a problem is identified, the car owner, shipper or other involved parties 
are requested to furnish supplementary information, and usually is invited to 



APPENDIX E -72- 



present evidence and answer specific questions posed by the Tank Car 
Committee. FRA is notified of all verified significant problems that concern 
hazardous materials transportation. 

What assurance is there that the problem is restricted only to the group of cars the 
manufacturer removed from service? 

Appropriate record searches are utilized by AAR to uncover car similarities 
and /or past incidences. However, there are other strong reasons why the car 
owner or shipper having been notified of a potential problem, responds in a 
responsible manner. The owner or shipper recognizes the liability incurred by 
knowingly permitting cars with identified problems to continue to operate. 

Were the above procedures followed by car companies and AAR following North 
Little Rock, Arkansas; Elkhart, Indiana; Seattle, Washington (Richmond Tank Co.); 
and Miamisburg, Ohio? Are these actions adequate in identifying permanent 
solutions to industry-wide problems? How? Why? 

The above procedures have been followed whenever a problem has been 
identified. We believe that the resultant AAR actions have generally been 
adequate. The tank car safety record is extremely good. Of course there is 
always room for improvement, and AAR is evaluating and implementing new 
tools and procedures to upgrade effectiveness. 



Fire 



Fire 



-73- 

APPENDIX F 
EXCERPTS FROM RELEVANT EMERGENCY GUIDES FOR PHOSPHORUS 

DOT Guide #38. 1980 



Some of these materials may react violently with water. 

Small Fires: Dry chemical, soda ash or lime. 

Large Fires: Flood with water. 

Do not get water inside container. 

Move container from fire area if you can do it without risk. 

Cool containers that are exposed to flames with water from the side until well after 

fire is out. 

For massive fire in cargo area, use unmanned hose holder or monitor nozzles. If this 

is impossible, withdraw from area and let fire burn. 



DOT Guide #38. 1984 



Small Fires: Cover with sand, earth or water spray and keep it wet. 

Large Fires: Water spray, or fog. 

Do not scatter spilled material with more water than needed for fire control. 

Move container from fire area if you can do it without risk. 

Cool containers that are exposed to flames with water from the side until well after 

fire is out. 

For massive fire in cargo area, use unmanned hose holder or monitor nozzles. If this 

is impossible, withdraw from area and let fire burn. 

AAR/Chessie System Form 

Emergency Handling Precaution for Hazardous Commodity 4916141 

Phosphorus, White or Yellow, in Water 

If material on fire or involved in fire: 
Flood with water. 

When fire is out, cover all suspected material with wet sand or earth, until material 
can be permantely disposed of. 

Envirnomental considerations— water spill: 

Use natural deep water pockets, excavated lagoons, or sandbag barriers to trap 
material at bottom. 

Environmental considerations— air spill: 

Apply water spray or mist to knock down vapors 
Combustion products include corrosive or toxic vapors 



APPENDIX F -74- 

National Fire Protection Association Guide 49: Phosphorus 

Phosphorus, White, or Yellow 

Description : Colorless to yellow, translucent, soft waxy solid. 

Fire and Explosion Hazards : Unites spontaneously on contact with air at or above 80" F. 
Explosive when mixed with oxidizing materials. 

Life Hazard : Fumes from burning phsophorus are highly irritating but slightly toxic except 
in very high concentrations. Solid yellow phosphorus causes severe burns. Avoid skin or 
eye contact. 

Personal Proctection : Wear flame-retardant full-protective clothing. 

Fire Fighting Phases ; Deluge with water, taking care not to scatter, until fire is 
extinguished and phosphorus has solidified, then cover with wet sand or dirt. 

Reactivity; 

Sulfur: when a mixture of sulfur and yelow phosphorus is warmed, the two elements unite 
in all proportions with vivid combustion and power explosions. 

Ann. Chim. et Phys. (1) 4:1 Ann. Chim. et Phys. (2) 67:332 Comp. Rend. 96:1499, 1771. R. 
Bottger, J. Prakt. Chem. (1) 12:357 (1837). See Phosphorus plus Cesium. 

CHEMTREC: File Card for Phosphorus 

For phosphorus tank car fire: 

Cool with water from the side 

Stay up-wind 

Use unmanned hose monitors; if unable to withdraw 

Do not use high pressure hose stream; use flooding amounts of water spray or fog 

Refer to DOT ERG(1984) for guide reference; reactivity: avoid air, organic matter, 

peroxides, etc. produces P408 



-75- 



APPENDIX F 



CANADIAN EMERGENCY FORM FOR PHOSPHORUS 

V »„. ' ..... _ /^ 






SPECIAL COMMODITY 



Phosphorus, Yellow, 
Under Water UN 1381 

Spontaneously combustible 4.2 

Immediate Action Information 
on other side of this sheet 

GENERAL 
CHARACTERISTICS 

Phosphorus is a wax-like solid, insoluble in water. It isj 
usually shipped under a blanket of water to protect \i 
from air. If the phosphorus becomes exposed to air it 
spontaneously ignites. Contact with the matenal causes: 
s^ere bums It is extremely poisonous by ingestion. 
Boiling point: 280 °C 
Melting point: 44*C 



POTENTIAL HAZARDS 

Fire: 

Igndes spontaneously when dry. Reacts violently with 
organic compounds and many other chemicals. Heated 
containers may rupture violently. Water is the best fire 
fighting agent for large fires On burning, releases dense 
irritating white fumes. 

Explosion: 

Not explosive but, when contained, heating may cause 
a violent rupture. Contact with certain reactive materials 
may cause an explosion. 

I 

Health: ' 

Contact with skin or eyes may cause severe burns, j 
Irritant fumes are produced during combustion Some ■ 
effects of inhalation may be delayed for 24 hours, i 
Residues from decomposition are corrosive. Highly i 
toxic if swallowed. ' 



marchandise speciale 



Phosphore, Jaune, 
Recouvert d'eau UN 1381 

Matiere s'enflammant spontanement 4.2 
Mesures d'urgence au verso 

RENSEIGNEMENTS 
GENERAUX 

Le phosphore est une solide cireux, insoluble dans 
I'eau. II est normalement expddi^ immerge dans Teau « 
pour le prot^ger de I'air. Si le phosphore est expo6^ k , 
I'air il s'enflamme spontanement. Un contact avec ce 
produit causera des brOlures s^v^res. II est extr£me- 
ment toxique par ingestion. 
Point d'^bullition: 280*C 
Point de fusion: 44'C 



DANGERS 



Incendie: 

S'enflamme spontanement k Tetat sec. Reagit violem- 
ment avec les composes organiques et divers aufres 
produits chimiques. Les contenants surchauffes 
peuvent se rompre violemment. L'eau est la meilleure 
substance pour combattre les incendies majeurs En 
brulant, d^gage une fumee blanche dense et imtante. 



Explosion: 

Le phosphore n'esf pas explosif. Toutefois. lorsqoe 
enferme, un nsque d'explosion peut se produire si la 
temperature est suffisamment elev^e Le contact avec 
certains matenaux reactifs peut provoquer une 
explosion. 

Sante: 

Le contact avec la peau ou les yeux peut causer de 
severes bnCilures llyadegagementde vapeursimtantes 
lors de la combustion. Certains effets de I'mhalation 
peuvent Sfre retardes de 24 heures Les residus 
provenant de la decomp)osition sont corroafs Forlement 
toxique si ingeste. 






APPENDIX F 



-76- 



un\ji 



g 



Wagon .■;Benio.gue CcnieneM ^ ^i.-''Jfj,\i:\-Jr J ff 'tfr^i-, ■' ■■ 







^^ Emergency Response Form "^■"•^i.-'.'v''-,^ 

^ SPECIAL COMMUDITYi^i^^s^ 

^^^ Additional iriforfnation'brv'other sicle"*' ^^'^*' 

^ Phosphorus, Yellow,^^ 
f^ Under Water U 1^1381 ^^l& 

'^^ Spontaneously combustible 4,2 j'i- iij^ i v2 ' 



1^ I 

:■* -.■■ij.v_ -Tt* 



i^^^^''^:'^Fiche^e^s^tjHte 

i v-JVI/^CHANJblSE^ 

,KyRense1gnemehts additibnnels"^u^verso 

%^kr<^: Phosphore,Jaune, 
mRecxyuvert d'eauUN 1381 

f Matiere senflammant spontanement 4.2 



ippe^-designated 24-hotMefneiveri(^ leiephbne numbers '^■.■"*.''?^%^^5Tj » 
de l6l6phore toofnls oat Texp^diteur en cas tfiwgence [2^ jieures aw 24). 

I 514-652-2911^ 



m^mmim 



IMMEDIATE ACTION 1>.^; 

;iNF0RMATI0N2:SSi|;C:| 

'General: '^^^^-■^^^f^;^ M^^ M^'^ I 

■;Keep )jpwind No unnecessary personnel. Avoid contact with the.7j 
^•matenaland inhalation of fumes. Wear (ulf protective clothing and &eW-,> 
."";Jor tamed breathfr^g apparatus (SCBAJ, Do nol handle broken packages j 
^'.without full protective equipment H safe procedures permit, transport jj 
•unbroken containers to_a safe place. Isolate hazardarea" Minimizef 
escape of phospnqrus or'of water which has contacted it ''^'r.'^t* -^f 

Sp\\\ or l^ak:te.,£^t:J. V^^J:!^^:^ ^ 

ilhout risk, or cool container]© soJfdify contents Notify J 



I 




-Stop leak if 

. Ihe shipper immediately that experts are required for^area decoi 
■'lamination Build dikes as riecessary and keep spilled material covered 
with water, Keep area wet with flooding quantities of water spray. tt- 
possible, collect rpn-off water for subsequent recovery. Remove 
: clothing suspected of contamination as soon as possible and wast\or' 
nerse m water Immediately. 

"'-^ -4 



::-.^ ■■?-:'■; 






.First Aid:'"-#' 



Cover small fires wflh water, sand or earth- For large fire, use a low- 
-pressure water spray Use water in flooding guantitjes'as a fog Ifan^ 
^'engulfing tire tt^reatens but safe orocedure permils.set up unmanned^ 
; hose streams. Use water to cool containers exposed to fire. ■^,, 

Wash material from skin with water Flush eyes ar^d skm burns with low' 
pressure water for at least 30 minutes, or cover sKjn burns with wet 
dressings soaked in 5% sodium bicarbonate solution for burns!^ 
swatlowtng or fume exposure, prompt medical attention is essential If^ 
fumes have caused diffcult breathing, administer oxygea If swallowir>g 
of phosphorus or of the blankenmg water is suspected, induce vomiting. 
Keep patient at rest, "l^v'-^ * .1^ ' ^S' •"# '.?1^"-;- -"^-^'V*^-'- •■-.'' 



im 



%K^- 



':^.-^^^ 



iester en amont du vent Pas de perso'nnef Inutile.'Eviter tout contact v* 
I vec le produit et rinhalatidn des vapeJrs^ Porteruhe teriue Ci&pro-^-_ 
) ?ction complete et un apparel! respiratoire autojtorne. Ne pas martlpuler^i^ 
ies emballages abFrn^s saris ^quipement de ^otection complet Si ta'^J- 
ecurlt6 le permet. transporter Ies contenants non endommag^s dan**.^ 
in enOroit sCir Isofer la zone dangereuse. Minimisef r^chappement du;^ 

thosphore et de Teau qui vest entr^ en'oontact-"^ -£-fcf ^^' J^eTs . 
)eversement •6u\fuiten^^:#4^Wlfe 

Suppnmez la fuite, s'tl n'y pas de risques ou refroidissez les'contena'nfs '* 
ivec de feau pour solidifier son contenu. Demander imm^dialemerU a 
'exp^diteur d'envoyer des experts pour netloyer (a zone. Au besoin" 
jndigueret garde r le produit recouvert d'eau GarderTa zone moi>in^ 
wee des quantit^s abondantes d'eau en piute Si possible ramasser' 
'eau phosphor^e pour r^utilisalibn, Eniever le plus tftt possible tout 
z&lement pouvant avoir 6te contamm^ et laver ou im merger dapsde "^ 
'eau Dn mediate me nt. ■_' '^ ■^vV""'*^^"' '^^''^r^'^";^'*^ "^ 

Incendie:'';;;!^?; i'^V-^'^J.V j-jj^;:; ;/?y^^ 

Pour tes incendies mine'urs, recouvrlr cfea'u, de sable'ou de'fer're.Voui^ 

Jes incendies maieurs, \jliliser de feau i basse pression sous forme de' 'v 

'ui'e. Arroserabonda.mment avec de I'eau en brouillani Si TincendieV" 

et installer des boyauxfixes. non f 

! I'eau pour,refro'dir Ies contenants";, 

|Secourisme: ^^r^^'^;ii^-ni^y^-!^':Hi^^'i^s^-' 

iLaver la peau avec de feau pour enlever le pro<3uit. En casdeSrDlure,"^. 
rirv^er abondamment Ies yeux ou la partie toucti^e avec de feau fi l^asse Y 
Ipression pendant au moins 30 minutes, ou mouillez-les avec un ltnge^ 
imbib^d'une solution de bicartwnatede soude 5%. Suite auxbrulures. S^" 
Tingestion ou A une exposition aux fum^es, des soins rD^dicaux Orients* - 
Isont essentiels Si la victime a respir^ deslum^es de I'lncendie/C 
administrer-lul de foxy^fene si 'a respiration est difficile, ^rovoquer le*^ 
^|omissement SI t'on suspecte I'lngestion du pfiosphore ou de feau' 
^hoEp^vor6e Garder la^victime au repos_ T[f,«4- j^; /> I'^^l;.^''^. 



inenace et que la security le pen 

bp^res par du personnel Utiliser de I'eau pour,refroidir 

Jexposes au feu. "" - * - -''■ » ^-* ' ^■-- ---* . ^ -. 



. Placard Notation. , -'SPONTANEOUSLY COMBUSTIBLE 4"'PLAC| 
Mention d'eliquelage PANNEAUX -INFLAMMABLE SPONTAN^ME 
•JT - -. ■ - ■ ii--' ■_'.<•( <^'' i't »• •■ 1- • ■■ ■'■-■ s,'- r-r-./i 

Shipper: ERCO. a division o( Tenneco Canada Inc. i.-Vj/""^ 
ExpediieurERCO. une division de Tenneco Canada Inc. ,");''.; J 

Consignee: 
Deslmalaire: 



•-Origin, 
Ongine: 



VARENNES (QUEBEC) 



RDS APPLIED 
T 4" APPLIQUES 
,'4.i.si-Vv\.\!--'( ■ ,-.«;*-- -A.-' r^i'jn , ., _ 
estmation. .^^_^j£RNALj) '0^0 U.S. A; 
Destination- -' ■' . - . . 



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-77- 

APPENDK G 

CANADIAN RAILWAYS TRANSPORT COMMITTEE 
BOARD OF INQIRY: MACMILLAN YARD ACCIDENT 

CTC'S RELATIONSHIP WITH AAR 

Prior to CP Rail's accident at Mississauga, with its immediate 
holocaust that enveloped most of the 21 tank cars derailed, the prevailing 
philosophy of the Canadian Transport Commission in certain critical areas of 
expertise was to rely heavily on the Association of American Railroads (the 
AAR). Design and specifications of tank cars were considered to be the 
province of the competent and knowledgeable Tank Car Connnittee of the AAR. 
The assignment of such responsibilities to the jurisdiction of the trade as- 
sociation of American railroads was not perceived, at the time, as being in 
any way unusual ~ it was, or so it seemed, just being practical. 

This ingrained philosophy persisted as tank cars got bigger and 
their respective ladings ever more diverse and deadly. The thinking was on a 
more positive note in the months leading up to Mississauga but it was not, as 
yet, distinguished by involvement and action. 

The void did not escape the attention of the Grange Royal Commis- 
sion inquiry. The Canadian General Transit Company, pointing to the void, 
proposed to the Royal Commission that it be filled in this way: 

"A trade association or branch of the CTC ought to be 
created to re-evaluate performance standards of all 
safety devices and analyze all retrofit proposals on a 
cost/benefit/risk basis. This body ought to have the 
research capability and liaise with the DOT, FRA (Federal 
Railroad Administration), RPI (the Railway Progress 
Institute ~ suppliers of equipment to railways), AAR and 
appropriate trade associations such as the Chlorine 
Institute." 

The Royal Commissioner himself addressed the matter in his report. 
Dealing with the CTC Red Book, at page 113 of his report, he stated: 

"The difficulty, if there is one, is that it follows 
almost inevitably that the initiative in the field lies 
with the AAR. While Canadian railways and indeed 
Canadian manufacturers and shippers are members or as- 
sociate members of that organization there is no 
contribution to its deliberations on behalf of the 
Canadian public." 

Later, turning to problems demonstrated at Mississauga with tank 
cars, the Royal Commissioner at page 152 of his report, stated: 

"These problems are all being worked on but they are not 
being worked on in Canada. Their solution seems to be 
left to the AAR Tank Car Committee which may perhaps be 
affected by the recommendations of the National Transpor- 
tation Safety Board. I have no doubt that the Canadian 
railways and the Canadian tank and car manufacturing 



APPENDIX G -78- 



companies and shippers contribute to the AAR delibera- 
tions, but it is not in my opinion enough to rely on 
private and American efforts. We are concerned with the 
transportation of dangerous goods in Canada. We must 
take advantage of all knowledge to be obtained from any 
source but we must also attack the problems from the 
viewpoint of the Canadian public and I am sure there is 
in Canada knowledge and talent available to help." 

Canadian National Railways, as one of the chief parties to the 
inquiry I conducted (the incident having occurred in its yard), addressed the 
concerns and opinion that, through the words of Mr. Justice Grange, I 
introduced for consideration of the parties. In final argument, CN produced 
a succinct statement as to the purpose and functions of the AAR. There seems 
to have been little actual evidence about AAR, although there were very many 
references to it. I am aware, of course, that my colleagues and the parties 
to the inquiry all know the role of AAR. So that the record will be clear in 
this report, and as background to the views of parties who responded on this 
subject, I avail myself of relevant information about AAR as found in the CN 
argument. 

CN pointed out that the most important role of AAR — an associa- 
tion of almost all North American railways ~ involved the setting and 
enforcing of rules and standards relating to the interchange of both traffic 
and equipment. It provided a forum in which matters of common interest could 
be discussed and analyzed. According to CN: 

"It is a self-regulating agency which can provide 
technical, and other, assistance both to its members and 
any other group that requires its expertise. The As- 
sociation is interested in safety matters and efficient 
and technically correct operation of the railways and its 
membership is such that it can draw upon a substantial 
body of technical knowledge." 

CN emphasized, too, the activity of AAR relating to international 
trade and, in consequence, the interchange of equipment back and forth across 
the United States-Canadian border: 

"It is also important to bear in mind that the AAR 
operates in a geographical territory over which no single 
regulatory body has complete jurisdiction and, thus, to a 
large extent, performs a necessary coordinating 
function." 

CN stated that "a parallel can be drawn between the AAR in railway 
transportation matters and Lloyds of London in maritime shipping matters". 

CN also gave me its views on the matter at hand. These are as 
follows: 



-79- APPENDIX G 

"Admittedly, the AAR does not possess a status similar to 
a regulatory agency but, it is our submission that this 
Association is in an excellent position to provide en- 
lightened and meaningful advice to regulators and 
industries on both sides of the border. For example, the 
AAR, working in conjunction with the tank car companies, 
has investigated the causes of all significant loss of 
lading incidents and, as a result of these investiga- 
tions, suggested to regulatory bodies major improvements 
to tank car head shields, insulation and top and bottom 
shelf couplers (here, reference may be made to the 
testimony of Dr. Harris at the 1981 Show Cause Hearing 
given at Hull, Quebec on April 27. 1981, Volume 5. pages 
608 to 622). Such advice is given with a view to 
improving safety and protecting and enhancing interna- 
tional trade. It is respectfully submitted that the RTC 
would be ill-advised to ignore the advice, and the 
contribution, of a body of experts of this nature. 

It is respectfully submitted that, in the present case, 
the AAR can be relied upon to assist Canadian railways to 
coordinate with the RTC in eliminating the problem that 
has obviously provoked concerns. The RTC has undertaken 
the investigation necessary to determine the cause of the 
Incident MacMillan Yard and, further, has taken immediate 
steps to ensure that there are no other cars with a 
similar defect operating on Canadian Railways. Thus, In 
our submission, the RTC has acted quickly to eliminate 
the problem without adverse effects in the realm of 
international trade between Canada and its much larger 
partner, the United States. 

Clearly, however, the RTC is in no position to ignore the 
long-term objective of ensuring that cars produced in the 
future will not have a similar- defect, but, it is our 
submission, that this objective is best pursued 
simultaneously in both Canada and the United States. 
Only then can the RTC be assured that the long-term 
objective of this Inquiry (ensuring that no more cars 
with a similar latent defect appear on our Railways) is 
achieved without intolerable consequences for interna- 
tional competitive position of Canadian shippers and 
railways. Again, reference may be made to the decision 
of the RTC panel sitting on the 1981 "Show Cause 
Hearing": 

"In imposing safety prograiranes on the 
Railways under its jurisdiction, the 
Committee must therefore have regard to 
their probable cost and their effect on the 
competitive position of the Railways vis a 
vis other modes of transportation. This 



APPENDIX G -80- 



national transportation policy also 
prescribes as objectives protection of the 
interests of the users of transportation 
and the maintenance of the economic well- 
being of Canada. It declares that an 
economic, efficient and adequate 
transportation system making the best use 
of all available modes of transportation at 
the lowest total cost is essential in 
meeting these objectives. These statutory 
objectives also point out the requirement 
to ensure that interchange of commodities, 
development of industry and export trade 
are not unduly obstructed (at pages 11 and 
12)." 

In summary, though Canadian Railways must be regulated by 
the proper Canadian authority, it is essential to recall 
that such regulation cannot take place in a vacuum; it 
occurs in an international context, and in some cases, 
the regulator must carefully weigh the consequences his 
actions will have on international trade. In the present 
case, independent Canadian action could have severed 
economic consequences while coordination with other 
bodies concerned with North American railway traffic 
would avoid such consequences." 

Procor Limited, in final argument, favoured me with their views on 
the comments and opinion expressed by Mr. Justice Grange. Procor stated: 

"What he had in mind was not ignoring or duplicating the 
present system for tank car design and improval that is 
part of the work of the AAR Tank Car Committee; rather, 
he suggested that that process be augmented where neces- 
sary to adequately respond to Canadian problems. What he 
had in mind was that the CTC itself have an independent 
research activity." 

"This hearing and the work of the CTC staff clearly 
demonstrates the independent position of the CTC at the 
present time in dealing with Canadian problems." 

Procor was of the view that, in the circumstances of the inquiry, 
my reliance upon the Technical Committee was both consistent with the role 
Mr. Justice Grange envisioned that public authorities would play and would be 
the most appropriate and efficient response to questions raised by the 
MacMillan Yard incident. 

The Government of Ontario, in final argument, dealt with the com- 
ments and opinion of Mr. Justice Grange. The Government pointed out that the 
Technical (or Advisory) Committee which had assisted the inquiry had been 
unanimous in the view expressed to me in their report: 



-81- APPENDIX G 



"Recommended that the AAR Tank Car Specifications would 
be the best place to introduce all of the above mentioned 
recommendations most efficiently. The Tank Car Committee 
of AAR should be approached to process those recommenda- 
tions. Unanimous verbal agreement individually." 

The Government of Ontario believed that "intuitively this must be 
so" ~ the AAR was the body that made the rules for the American market and 
the American fleet. It was also clear, Ontario argued, that more resources 
were available on a continuing basis to AAR than to the Canadian regulatory 
authority. The Ontario Government's view, in respect of AAR, was that: 

"The difficulty is one of having adequate access to that 
body." 

"It would be our view that prior to attempting to 
replicate American facilities here in Canada that the 
Canadian Transport Commission attempt to gain access to 
the AAR deliberative process. This does not mean that 
the CTC should bind itself unreservedly to American 
standards. However, being a part of the deliberative 
process would permit the Commission to identify where its 
views differ from the American and where it would wish to 
depart from the American practice." 

That, in the Ontario Government's view, was the point that 
Mr. Justice Grange was addressing in his report on Mississauga. 

M-Trac's response to the issue posed by Mr. Justice Grange, and on 
which I asked for comment, reflected unease with the AAR's handling of the 
tank car situation and impatience with the Canadian regulatory authority's 
seeming passivity to AAR ascendancy: 

"A central question which arises from this inquiry is 
whether the Canadian Transport Commission and, through 
it, the Railway Transport Committee exercise sufficient 
control over the design, manufacture and operation of 
pressurized tank cars operating over Canadian track. 

In his 1980 report Mr. Justice Grange voiced criticism 
over the fact that much of this control rests in American 
hands. The car which failed, and cars similar to it, 
were designed in the United States, under the direction 
and supervision of the rail trade organization, the As- 
sociation of American Railroads. Note it is not 
Canadian-American, simply American. 

This reference is not intended to be unduly critical of 
the AAR or its Tank Car Committee. Nevertheless, we are 
a sovereign country with technical abilities and 
technical goals of our own and it is questionable whether 
we need to depend entirely on the American rail 



APPENDIX G -82- 



technicians to tell us what kind of pressurized tank cars 
should run on our tracks." 

According to M-Trac, it had been admitted during the inquiry that, 
in effect, the CTC had delegated its powers on design and production of 
112 tank cars to the AAR. It was true that the Red Book spoke of CTC 
approval "but in fact the CTC doesn't exercise much influence over the AAR 
and its Tank Car Committee". Yet the inquiry's Technical Committee was cal- 
ling now for greater scrutiny of the steel for tank cars and the production 
of tank cars. 

M-Trac made this point: 

"Looking ahead, we can see that chemical traffic is 
likely to take an increasing slice of overall rail 
traffic. Has the CTC given enough attention to this 
prospect? If we are to continue to lean on the AAR to 
ensure the production of safe tank cars — keeping the 
extremely low Canadian winter temperatures in mind — 
must we be resigned to relating our needs and our goals 
to those of the American rail industry? Must we 
constantly look southward for direction of our 
requirements? Surely, it is time for an assessment of 
our Canadian technical abilities and our needs." 

Canadian Pacific Limited did not, in fipal argument, deal with the 
Issue that I had raised through the medium of Mr. Justice Grange's observa- 
tions on Canadian public input in respect of AAR's work. 

The views expressed by the parties who responded have been of great 
assistance to me. They have illuminated an issue that beyond doubt — so far 
as I am concerned — must be wrenched from the wings, brought to centre stage 
and conclusively dealt with. It is an issue that challenges the professional 
capacity of the Canadian Transport Commission as a safety regulator of 
railways. What is required now is the administrative action that must be 
presumed to have been delayed by other matters seemingly more urgent. The 
submissions before me confirm that the issue remains as clearly elucidated in 
the Grange Royal Commission Report of 1980. 

What is not needed is an initiative by the Canadian Transport Com- 
mission seeded with nationalistic bias. (There is nothing of that in the 
comments and opinions expressed by Mr. Justice Grange.) We are not looking 
at new arrangements -- perhaps they should be called additional arrangements 
— that will undermine, in any way, activities of the AAR or interfere with 
the Canadian railways' commendable participation in, and contribution to, 
this important trade association of North American railways. 

What must be sought is a way of injecting meaningfully into the 
picture — in addition to "private and American efforts" of undoubted benefit 
to Canadian railways and users of their services — the Canadian public 
interest . In directing the Commission as to its regulatory mandate. 
Parliament, in its several statutes, has repetitively used the words "the 



-83- APPENDIX G 



public interest" — we are to uphold it. Surely, at the Canadian Transport 
Commission, there must come before all else the safety of Canadian citizens 
— including employees of the railways — amid all of our heterogeneous 
regulatory responsibilities in respect of the rail mode. 

I had the impression, particularly reading the argument of CN, that 
there is a rather important apple cart here — AAR and the Canadian railways' 
participation in it ~ and for heaven's sakes. Commissioner Magee, don't 
upset that apple cartl But I do not seek to do so. Why would I? No party 
to this inquiry counselled that I should pursue the matter with that negative 
objective. Strangely enough, in deciding what I should say to the Commis- 
sioners, I think I can walk a path that, in the main, meets the views of all 
of the parties (and still be resolute! ). I will try. 

A careful analysis of every view expressed by the parties reveals 
an emphasis on particular aspects of concern, mainly as to the depth of 
involvement and the extent of 'independent action', arising from any newly- 
installed capacity of the Canadian Transport Commission to respond to AAR 
dicta. There seems to be no cleavage between the parties on the essential 
principle — that being that the Commission's Railway Transport Committee 
ought to know what is going on. If Mr. Justice Grange, who analyzed the 
CTC's safety mandate in his Mississauga Royal Commission Report correctly, 
concluded that "the jurisdiction of the Commission and its committee in the 
government supervision and investigation of the railways is almost limitless" 
then — surely — the Commission i^ supposed to know. 

The advice which CN has given me in argument is correct, in my 
view, inasmuch as it addresses the importance of the Association of American 
Railroads and its essential coordinating role, both as regards interchange of 
freight cars and rendering Canadian and United States railway operations safe 
and compatible. I agree that the Canadian Transport Commission should be 
open on any occasion to "the advice, and the contribution of a body of 
experts of this nature" (AAR). 

I do not agree that on an occasion when the necessity is 
imperative the Canadian Transport Commission should refrain, or even shrink, 
from "independent Canadian action". 

I would expect that if satisfactory arrangements were in place as 
between the Commission and the Association seldom if ever would the necessity 
for independent action arise. When people with common goals — trade 
associations of the transportation industry and regulatory agencies of 
government, the latter with their public input ~ reason together about 
urgent safety problems it seems to me they are unlikely to disagree. I was 
occupied for 20 years in the first role and have been occupied in the second 
for the past 17 years. From that experience, I speak with conviction about 
establishing a meaningful and formalized communicative role between CTC and 
the AAR. 



APPENDIX G -84- 



I would rather have seen the Canadian railways try to bring this 
aboutl Perhaps — in the way they look at it — they have. But, despite the 
goodwill that is evident, does it really advance us very far along the path 
to read in CN's argument, in reference to the Technical Committee's report: 

"Further, Canadian National Railway Company undertakes to 
provide the RTC with regular reports on the handling of 
these recommendations by the AAR." 

As one of the Members of RTC, this is not for a moment an offer I 
would disdain. But is it the complete answer to a kind of relationship that 
enables us to say that we — the Canadian Transport Commission — have ar- 
rangements in place that meet fundamental requirements of the Canadian public 
interest? 

Procor has told me in argument that these fundamental requirements 
of the Canadian public interest — what might be called the Grange format (as 
to which Procor itself expresses no disagreement whatever) — have been met 
in the practices and methodology followed in the inquiry, particularly the 
establishment and work of the inquiry's Technical Committee. I would, of 
course, be pleased to think that that is so. However, one must not lose 
sight of the fact that what was in effect in this instance was an ad hoc ar- 
rangement designed for problems confronting one particular public inquiry. 

If the Canadian Government is serious about the Canadian Transport 
Commission's railway safety mandate — and I have every reason to believe 
that it is — what must be put in place in Canada are not merely ad hoc 
arrangements in reference to the Canadian regulatory authority and AAR. What 
must be in place in Canada is formal, friendly but firm communication between 
the Canadian regulatory authority and AAR as to what, in Washington, D.C., 
the Association there is approving for movement over 57,000 miles of railway 
track in Canada. There must be a settled, formal arrangement, with the 
funding and qualified staff required in Canada. 

Nothing less will give Canadians a 'handle' on what is decided by 
the Association in Washington, D.C., as to standards and specifications of 
the various types of tank cars traversing railways, in Canada. 

In cross-examination, Mr. Stanley Kaplan, Director, Dangerous Com- 
modities, gave his view of how much further we need to go: 

"Q.: Is the CTC part of the Tank Car Committee? 

A: No, neither is the CTC part of the CSA and neither is 
DOT part of ASME. 

What is extremely necessary, I might just say this, 
and this is a personal opinion, is that the government 
and the ruling body follows somehow what the Associa- 
tion is doing. I don't see the reason for government 
to report a work which is owned by somebody else 
already. 



-85- APPENDIX G 

What is important is just to be able to live with it, 
in that we follow up the development in the Associa- 
tion and that you will satisfy yourself that the work 
has gone on in the right way. 

Q,: So you would not recommend that the government be 
involved in the AAR Tank Car Committee? 

A.: No. I would not go that far. 

What I would say is that the government should keep 
track of what the Tank Car Committee is doing and what 
the developments are and participate with them when- 
ever there is developments, participating, maybe, on 
the technical side, and that I believe will be the 
appropriate mix." 

I am sensitive to the fact that, in time of restraint, the 
expansion of staff, rather than the diminution of it, is not popular, 
although the government, since it took power, has made special provision for 
the health and safety of citizens. No problem of the kind I am addressing 
has ever struck me as glorious potential for empire building. Twenty prior 
years in the private sector has made that reticence ingrained. The fact that 
our total safety-related staff ~ all aspects of rail safety, covering the 
whole of Canada ~ numbers 152 is evidence of the care that has been shown in 
approaching the matter of staffing for safety. 

So, too, in our equipment research and testing, whether before or 
after a railway accident: we have a contract with the Energy, Mines and 
Resources Ministry's excellent Physical Metallurgical Research Laboratories 
to do that kind of work for us rather than attempt to replicate such 
capability in the CTC. We have, too, a good working relationship with the 
National Research Council. 

Some new staff, but no large infusion of staff, will, in my view, 
give us, at last, a capability to observe, study and respond meaningfully to 
the work of AAR in terms of the Canadian public interest: 

"...it is not in my opinion enough to rely on private and 
American efforts..." 

"We are concerned with the transportation of dangerous 
goods in Canada." 

"We must take advantage of all knowledge to be obtained 
from any source..." 

"...we must also attack the problems from the viewpoint 
of the Canadian public..." 

"...I am sure there is in Canada knowledge and talent 
available to help." 



APPENDIX G -86 



It was recognized by Mr. Justice Grange that an AAR standard may, 
on the average, be acceptable to the Tank Car Committee members who prepared 
it. It may be acceptable to their respective 'constituencies' but these may 
or may not always include Canadian interests and concerns. It followed that 
Mr. Justice Grange felt that there was need for a review and evaluation 
mechanism that would function in Canada and, in respect of which, problems 
would be looked at from the viewpoint of the Canadian public. The 
performance of the ad hoc Technical Committee that served the RTC well in 
this inquiry bears out absolutely his surety that "there is in Canada 
knowledge and talent available to help". 

A means of reviewing and evaluating AAR standards on behalf of the 
Canadian public should be created as a specialized advisory group under the 
aegis of the Commission's Railway Transport Committee. It must not be 
insular -- confined to RTC alone -- but should be structured, if possible, to 
tap knowledge and talent available to help, both inside and outside the 
Government of Canada and its agencies. 

The organizational unit that is proposed should develop and 
maintain close relations with the AAR Tank Car Committee and there should 
emerge from this a two-way flow of information on activities and conclusions. 
An invitation to attend any meeting of the AAR Tank Car Committee at which 
our findings or technical expertise are sought by the Committee should be 
accepted forthwith — in terms of public safety it is undeniably one of the 
most important bodies on the North American continent. 

As well, the RTC organizational unit should maintain equally close 
ties with the Canadian railways, the tank car manufacturers, dangerous com- 
modity tank car users, public bodies concerned with rail safety, research 
organizations, standards associations ~ all who have interests in dangerous 
corranodity tank car design and specifications. The object here should be 
adequate and comprehensive Canadian input to the proposed unit. 

The overall objective is to utilize all developments of the AAR in 
the context of Canadian evaluation of standards and design specifications of 
tank cars running on Canadian railway tracks. If shortcomings or omissions 
are found there must be Canadian action to 'fill the gap', always in inter- 
action with the interests who have direct concern. 

Review and evaluation capacity in terms of tank car standards 
should be housed in the Railway Transport Committee, Regionally and at Head- 
quarters, in a readily identifiable organizational unit. It must not be 
obscured. Its expert staff should be armed with a clearly defined mandate, 
known and understood outside the Canadian Transport Commission. Contact 
points should be "up front". The communication policy should be one of ready 
access to all concerned within CTC — and it is emphasized, in another 
section, that this communication ought to be outgoing as well. 

The work of this expert group should be so structured and directed 
that every category of dangerous commodity tank car in Canada — presumed 
healthy or suspect, either having been involved in, or believed to have 
precipated, an accident — is a known quantity to the Railway Transport Com- 



-87- APPENDIX G 

mittee and a candidate for its action when deemed appropriate. All types of 
these cars, as they have passed through the AAR Tank Car Committee, will in, 
due course, have been reported upon to the RTC. When considered safe they 
should be formally approved in that regard. When it appears that a car type 
presumed healthy with no past record is now beginning to exhibit an inherent 
flaw this would be reported immediately to the RTC by the AAR and dealt with 
as circumstances require on both sides of the border. 

"Action when deemed appropriate", as the need is perceived by RTC, 
should involve communication with the AAR and owners and operators of the 
equipment, together with such follow-up action as may be severally possible, 
but, failing that, by RTC unilateral action. 

The RTC group should conduct its reviews and evaluations on a 
priority basis. Dangerous commodity tank cars should come first — foremost 
among them, and of No. 1 priority, those carrying CTC-rated "Special 
Dangerous Commodities" — the most dangerous of dangerous commodities listed 
in the Red Book. Later, as time permits, the other tank cars can be examined 
on a descending scale of priority, determined by the relative dangers of the 
lading regularly carried in each of these types of car. 

During the preparation of this report there were, within RTC, two 
waves of special inspections of tank cars. The group whose formation I 
suggest should not only avail itself of any inspection reports, whether a 
product of regular or special inspections, but should be authorized to set in 
motion inspections associated with review of any tank car category. Such 
inspections should be carried out either by our Regional or Headquarters 
staff, as deemed appropriate in the circumstances. 

The new structure in place in the Committee should continue our 
policy of making full use of available expertise and facilities within the 
Government of Canada — some already referred to in this report — thereby 
avoiding duplication of publicly-financed resources. The specialized RTC 
staff should, of course, avail itself as well of available resources in the 
Research Branch of the Commission. (Research has made, in addition to RTC's 
staff, a contribution of consistency and excellence in respect of our 
accident investigations.) 

Even if the times and circumstances were opportune, I would not 
recommend the luxury of duplication of technical research facilities of AAR. 
In order to eradicate the void to which Mr. Justice Grange drew attention, 
this is not necessary in my view and I agree also that that precise course of 
action is not what Mr. Justice Grange intended. What is required is that the 
new group should be staffed by experts of the 'senior' variety and that they 
should have the qualifications and capacity to select, and make best use of, 
specialists, both inside and outside the Commission — specialists in the 
technical and economic and risk evaluation fields, drawn from agencies of 
government and from private industry as well. This, by definition, requires 
an assigned budget to buy the diverse expertise required. 

What I am confronting here is the health and safety of Canadian 
citizens in the face of an ever-increasing flow of dangerous commodity 



APPENDIX G -88- 



traffic on the railways of Canada. The budget of the RTC group in liaison 
with AAR should, therefore, be inviolate. It should be administered by the 
unit itself, subject only to the appropriate checks, in terms of propriety, 
by the designated officers and agencies of the government. 

Already stated is my belief that some new staff, but no large 
Infusion of staff at this stage, would give us, at long last, a capability to 
observe, to study, and to respond meaningfully to, the important work of AAR. 
In part, that belief is based on the modest staffing —numerically ~ that I 
see as necessary. But that is only part of the foundation upon which my 
expectations rest. 

It must not be forgotten — indeed we +iave been reminded of it in 
the arguments of the parties — that the tank inquiry was assisted from the 
outset by an ad hoc Technical Coiranittee that consisted of technical and 
expert persons drawn from the Railway Transport Committee: CN and CP Rail; 
the Association of American Railroads; M-Trac (having nominated 
Professor Weatherly from the University of Toronto); Procor Limited; Energy, 
Mines and Resources; and the Bureau of Explosives (AAR). This team worked 
efficiently and effectively in drawing conclusions, and in reaching 
concensus, on a very difficult and complex technical problem — the cause of 
failure of UTLX 98646 and action proposed in respect thereof. Having regard 
for the somewhat adversarial atmosphere in which such hearings often start 
off, I was astonished and pleased by the Technical Committee's achievement. 

What we saw in action here, and as a major contribution to uncover- 
ing the mysteries of UTLX 98646, was a multi-interest group ~ one of proven 
viability in respect of deliberations that, at some future time, will again 
be required of RTC. 

It is my impression that most, perhaps all, of the parties to the 
hearing would support the continued participation of its officers or assigned 
experts to a committee of this kind. This was primarily because of the 
perceived potential to reduce time and money spent to resolve the cause and 
implications of an incident. But my strong view is that there could well be 
another benefit — that of review and evaluation of existing and new AAR 
standards in terms of their applicability in Canada. As was the case at my 
inquiry conducted on behalf of RTC, the Technical Committee in this role 
would not be the arbiter but would report to RTC. 

It is well worth following up this development — to see if there 
is here a useful, long-term mechanism, capable of interaction with the expert 
staff of the proposed new unit, the object being to enable RTC to get a more 
meaningful grasp on tank car standards and design specifications. 

What will the proposed additional capacity of review and evaluation 
by the Railway Transport Committee achieve? 

It will better protect the safety of the Canadian public by 
substituting a formal structure for ad hoc response in Canadian surveillance 
and regulation of design and specifications standards originating with the 
Association of American Railroads. 



-89- APPENDIX G 



When that is done, it will better protect the safety of Canadians. 
It win butress significantly the credibility of the Railway Transport Com- 
mittee at accident investigative hearings. Commissioners will be relieved of 
an experience that I, for one, have found demeaning — that of stolidly 
receiving evidence about a failed dangerous commodity tank car, with design 
and specifications standards approved by the AAR in Washington, D.C., but 
having been subject to no meaningful review and approval in Canada for opera- 
tions on railway lines passing through thousands of Canadian coirenunities. 

As one looks at Sections 227, 228 and 296(1) of the Railway Act ~ 
to cite examples in the statutes — more is required of us than that. 

Subject to the availability of the supplemental staff unit 
required, hopefully with the contemplated interaction of the ad hoc Technical 
Committee, I recommend to the Railway Transport Committee that it: 

(1) Review and evaluate existing and new AAR design and 
specifications standards for tank cars designated 
for dangerous commodity service to ensure adequacy 
in the context of the Canadian environment and 
circumstances. 

(2) Develop proposed changes (additions, deletions, mod- 
ifications) to the aforesaid AAR standards, if 
necessary, to ensure adequacy in the context of the 
Canadian environment and circumstances, making use 
of all available Canadian talent and facilities, 
including consideration of risk reduction and the 
economic and trade implications of such changes. 

(3) Evaluate risk reduction, cost and other implications 
of implementation associated with the proposed 
changes. 

(4) Prepare recommendations to the RTC for implementing 
those proposed changes which appear worthwhile from 
a technical and cost-benefit point of view. 

(5) Ensure compliance with the aforesaid standards 
through monitoring, inspection and enforcement 
programs. 

(6) Administer a specific budget and staff to facilitate 
the above. 

(7) Prepare reports and advisory memoranda to the RTC 
Commissioners pertaining to the mandated duties. 



APPENDIX G -go- 



es) Maintain close liaison and observer status with the 
AAR Tank Car Committee, and close liaison with 
Canadian railways, tank car manufacturers and 
dangerous commodity tank car owners and users, 
public organizations and other interested parties. 

(9) Develop an ongoing relationship with an advisory 
technical committee consisting of representatives 
from such bodies as CN,. CP, the tank car industry, 
M-Trac, NRC and EMR (that committee to consist of no 
more than ten members). 

(10) Conduct liaison, as necessary, with interested 
public and governmental bodies and otherwise ensure 
public knowledge of the Committee's activities and 
results. 

The changes set out so as to strengthen our administration of the 
law ~ and to give us a formal budgeted structure that will end a partial 
void north of the 49^^^ parallel in regard to overseeing and approval of tank 
car standards — could come to pass in another way than through this report: 
simply, on authority of the Committee's Chief Executive Officer, by taking 
the necessary steps to obtain approval of person-years and budget to enable 
us to exercise fully our regulatory powers. Other improvements in the past 
that were not quasi-judicial ~ requiring no formal Order or Decision ~ have 
been handled in that manner. 

My feeling, in respect of the responsibility being addressed here 
is that the views and conclusions of the whole Committee — all of its Com- 
missioner-Members ~ will be constructive and helpful and, affirmatively, 
will add authority in moving towards our objective. In this way, the matter 
will be understood not merely as one of additional staffing but as a further 
initiative of the Railway Transport Committee pursuant to the safety laws 
that Parliament directs us to administer. 



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